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

We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from August 24, 2019 through August 27, 2019.
You asked the Plan to pay for inpatient mental health care. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. The rules say that inpatient psychiatric benefit days reduction and lifetime limitation 190 day limit. The member did not have any lifetime reserve days remaining. The member did not have a 60-day break in stay, therefore, a new benefit period has not started. The facility has been confirmed as free standing via search engine. Per guidelines, if the lifetime reserve period is at zero but there are lifetime psychiatric days remaining the benefit would be exhausted at a free standing. Therefore, we decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from August 24, 2019 through August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 15 extractions to be provided by an oral surgeon.
You asked the Plan to pre-approve the extractions. You say that too many of your teeth are broken and you are in pain. The Plan denied your request. The Plan says dental services performed by an oral surgeon are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by an oral surgeon. The contract clearly states that covered dental services are only covered when they are received by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve the 15 extractions to be provided by an oral surgeon.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 5, 2019 to December 23, 2019.You asked the Plan to pay for the skilled nursing services. You say that the enrollee was on hospice but discharged prior to their admission to the skilled nursing facility.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.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 dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from December 5, 2019 to December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 periapical x-ray (D0220), the panoramic x-ray (D0330), the pulp cap (D3120), 2 additional fillings (D2150), and the 2 pin retention (D2951) provided from November 29, 2018 to December 4, 2018.
You asked the Plan to pay for the periapical x-rays, the panoramic x-ray, 2 additional fillings, the pulp cap, and the pin retentions. You say that you and your wife both filed claims at the same time for dental services that you received at the same time. You say that your wife received payment. You also say that you were advised your claim was not filed on time. The Plan denied your request. The Plan says the periapical x-rays, panoramic x-ray, pin retentions and pulp cap are not listed as covered services. The Plan says that 2 fillings per calendar year are covered. The Plan also says that the frequency limit for fillings has been exceeded.
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 periapical x-rays, the panoramic x-
ray, the pulp cap, and the pin retentions received are not among those covered under this benefit. The 2 additional fillings are not covered because the frequency limit has been exceeded. The record shows that the Plan paid for 2 filling that you received on December 4, 2018. Therefore, we decided that the Plan does not have to pay for the 2 periapical x-ray (D0220), the panoramic x-ray (D0330), the pulp cap (D3120), 2 additional fillings (D2150), and the 2 pin retention (D2951) provided from November 29, 2018 to December 4, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe specialist office visit provided on December 4, 2019.You asked the Plan to waive the deductible forthe specialist office visit. You say that you should only pay a $45 copayment for a specialist office visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $250 copayment that applies towards in-network specialist office visits.The specialist office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 copayment that applies towards in-network specialist office visits. This cost sharing is a contractual obligation that had not been met at the time the specialist office visit was received on December 4, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe specialist office visit provided on December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe portable oxygen concentrator system purchased on October 3, 2019 from an out of network provider.You asked the Plan to reimburse you forthe portable oxygen concentrator. You say that you could not wait for a contracted provider and decided to pay out of pocket and submit for a reimbursement.The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network purchase.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 reimburse you 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 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. Purchased oxygen equipment is statutorily non-covered by Medicare. We found no exception that would require the Plan to reimburse you for these items/services.Therefore, we decided that the Plan does not have to reimburse you forthe portable oxygen concentrator system purchased on October 3, 2019 from an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Platelet Rich Plasma (PRP) Injections.You asked the Plan to pre-approve PRP injections in your knees. You say that you have knee pain and your doctor advised you that this procedure would be helpful.The Plan denied your request. The Plan says this procedure is not covered for your diagnosis.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PRP injections in your knees have not been met.Therefore, we decided that the Plan does not have to pre-approve Platelet Rich Plasma Injections
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesacroiliac (SI) joint surgery.You asked the Plan to pre-approveSI joint surgery. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 SI joint surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documented SI joint instability, fracture, or lesion. SI joint fusion surgery remains experimental. More long term outcomes studies are needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI joint surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve3 extractions of erupted teeth (D7210), alveoloplasty in conjunction with extractions -four or more teeth or tooth spaces, per quadrant (D7310), and alveoloplasty in conjunction with extractions -one to three teeth or tooth spaces, per quadrant (D7311) to be provided by a periodontist.You asked the Plan to pre-approve3 extractions of erupted teeth, alveoloplasty in conjunction with extractions -four or more teeth or tooth spaces, per quadrant, and alveoloplasty in conjunction with extractions -one to three teeth or tooth spaces, per quadrant to be provided by a periodontist. You say that the services are necessary.The Plan denied your request. The Plan says covered dental services must be performed by a participating general dentist. Therefore, coverage criteria has not been met.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 certain dental services performed by a participating general dentist.We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of 3 extractions of erupted teeth, alveoloplasty in conjunction with extractions -four or more teeth or tooth spaces, per quadrant, and alveoloplasty in conjunction with extractions -one to three teeth or tooth spaces, per quadrant to be provided by a periodontist have not been met.Therefore, we decided that the Plan does not have to pre-approve3 extractions of erupted teeth (D7210), alveoloplasty in conjunction with extractions -four or more teeth or tooth spaces, per quadrant (D7310), and alveoloplasty in conjunction with extractions -one to three teeth or tooth spaces, per quadrant (D7311) to be provided by a periodontist.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve4 additional physical therapy visits.You asked the Plan to pre-approve4 additional physical therapy visits. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 4 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found given the number of treatments already provided, you appear to have reached a plateau in improvement. Physical therapy provided in excess of what is medically necessary may promote dependence on therapy provided treatments rather than a regularly performed home exercise program. A daily maintenance home exercise programwith caregiver assistance would best meet your needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 additional physical therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve4 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on October 18, 2019.
You asked the Plan to pay for the services. You say that this is medically necessary, as the diagnosis billed is valid for the procedure code. The Plan denied your request. The Plan says both the referring and rendering providers are non-participating.
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 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 for lab services provided to the enrollee on October 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve skilled nursing services. You say that your caregiver knows you needs. You say that you feel comfortable with your caregiver and speaks Spanish. The Plan denied your request. The Plan says there are in-network providers who can provide these services and speak Spanish.
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 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. 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-approve skilled nursing services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve laser skin therapy.
You asked the Plan to pre-approve laser skin therapy. You say that the services are necessary because you are at a higher risk for fatal carcinoma. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve laser skin therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found phototherapy with excimer ultraviolet B-rays (UVB) laser treatment is a standard of care of vitiligo lesions. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of laser skin therapy have been met. Therefore, we decided that the Plan has to pre-approve laser skin therapy.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses and contacts purchased on November 1, 2019 from a non-contracted provider.You asked the Plan to pay for the items. You say that on the day of your visit you were told by the provider that you could not get your eyeglasses filled. You state you took both your contact and eyeglass prescription and found an online provider to fulfill the prescription.The Plan denied your request. The Plan says there are no call notes from the Plan or from the supplemental vision plan that indicate that you were provided misinformation.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. We looked at the file and the Plan's rules. The health plan contract says that routine eye exams and supplemental eyewear must be obtained from a provider in the Plan's supplemental vision vendor's network. Services obtained from vendors outside this network are not covered. You can find this information in Chapter 4 on page 63 of the plan's 2019 Evidence of Coverage.Medicare cannot make payment to a provider who does not accept Medicare payment. You never contacted the supplemental vision plan after your eye examination to find a participating provider to obtain the glasses with. You used anon-line vendor and the provider does not accept insurance nor Medicare payment.Therefore, we decided that the Plan does not have to pay for the eyeglasses and contacts purchased on November 1, 2019 from a non-contracted provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pathology examination provided on January 8, 2020.
You asked the Plan to waive the copayment for the pathology examination. You say that you should not be responsible for the $10 copayment because you already paid a copayment for seeing the doctor and having the biopsy. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for each Medicare-covered lab test. You have been asked to pay a $10 copayment for the pathology examination. The pathology examination 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 the pathology examination provided on January 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forSkilled Nursing Facility (SNF) care provided August 23 to September 21, 2019.You asked the Plan to pay forthe SNF services. You say that the SNF services were medically necessary.The Plan denied your request. The Plan says rules for coverage were not met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that the beneficiary does not require skilled nursing or therapy services on a daily basis.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 SNF services have not been met.Therefore, we decided that the Plan does not have to pay forSkilled Nursing Facility (SNF) care provided August 23 to September 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction services (92015) on November 26, 2019.
You asked the Plan to pay for the vision services. You say that you have paid the $40 copay and you do not believe you should have to pay anything further. The Plan denied your request. The Plan says this services is not covered under the plan benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine vision services if you purchase the enhanced vision, dental, and hearing package, which is an optional supplemental benefit for extra premium, routine vision services are covered. You can find this information on page 128 of the plan's 2019 Evidence of Coverage We looked at the file and the Plan's rules. Routine vision services are not covered under the plan benefits. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for refraction services (92015) on November 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pay forassistant surgeon services provided to the enrollee on October 9, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansayspayment is not allowed for this claim because RNFA is not recognized as a physician, per the Medicare guidelines.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by a physician, PA, NP, or CNS.Therefore, we decided that the Plandoes not haveto pay forassistant surgeon services provided to the enrollee on October 9, 2019