Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy provided on February 4, 2021, by an OON provider.
You asked the Plan to pay for the psychotherapy. You say that your physician renders medical care for the enrollees in the facility as requested by the facility. The Plan denied your request. The Plan says the services were rendered by a non-participating provider. The Plan also says that prior 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 the psychotherapy provided on February 4, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prophylaxis (D1110), the oral exam (D0120), and the vertical bitewing x-rays, 7 to 8 images, (D0277) provided on February 26, 2021 by an out of network dentist.
You asked the Plan to pay more for the dental service. You say that you did not know that your insurance reduces the out of network provider benefits. You say that you now understand that this service is not listed as covered. You also say that you would like this service to be covered. The Plan denied your request. The Plan says that vertical bitewings are not listed as a covered service.
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 vertical bitewing x-ray is not a covered benefit. Although prophylaxis and oral exam are covered services, out of network providers may bill you for any amount greater than the payment made by the Plan to the provider. Therefore, we decided that the Plan does not have to pay more for the prophylaxis (D1110), the oral exam (D0120), and the vertical bitewing x-rays, 7 to 8 images, (D0277) provided on February 26, 2021 by an out of network dentist
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the maxillofacial area.
You asked the Plan to pre-approve CT scan. You say that you have been treated for this condition since April 20, 2021 which is more than the required 3 weeks of conservative treatment. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no evidence of 3 weeks of failed conservative treatment.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that you do not meet the Medicare criteria for this CT scan. Our physician reviewer found the record indicates that you have significant reflux disease and globus sensation. You had a normal nasal endoscopy. The submitted documentation indicates that your treating provider believes your facial pain is caused by a migraine variant. You have a neurology appointment. The documentation submitted does not support the medical necessity and reasonableness of this scan at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve a Computed Tomography (CT) scan of the maxillofacial area.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, preventive procedure, panoramic x-ray, and two resin-based composites provided on February 8, 2021, and March 2, 2021.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, preventive procedure, panoramic x-ray, and resin-based composites. You say that you did not realize your dental insurance changed from last year. You also say that you were not aware that you did not have dental coverage. The Plan denied your request. The Plan says you do not have dental coverage under your plan for 2021.
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 the periodic oral evaluation, prophylaxis, preventive procedure, panoramic x-ray, and two resin-based composites provided on February 8, 2021, and March 2, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided on
October 29, 2020.

You asked the Plan to waive the copayment for outpatient hospital observation. You say that you should only
owe a $120 copayment for emergency care. 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 $250
copayment for outpatient hospital observation.

The record shows that you received outpatient hospital observation on October 29, 2020. Therefore, you are
responsible to pay the $250 copayment.

You have been asked to pay a $250 copayment for outpatient hospital observation. Outpatient hospital
observation falls within the outpatient hospital observation 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 hospital observation provided on October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office services with an out-of-network obstetrics/gynecology (OB/GYN) specialist.
You asked the Plan to pre-approve OB/GYN services. You say that you have been unable to find an in-network endometriosis excision specialist, and this doctor is one of the world's foremost experts on your condition. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network OB/GYN specialist.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 OB/GYN services. Our reviewer says that you do not meet the Medicare criteria for a network exception to see this provider. Our physician reviewer found you have polycystic ovary syndrome and endometriosis. The Plan has indicated that in-network providers are available, and that if the in-network provider indicates that an out-of-network referral is required the Plan would accommodate that request. The available medical records do not indicate that an out-of-network referral is 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 OB/GYN services have not been met. Therefore, we decided that the Plan does not have to pre-approve office services with an out-of-network obstetrics/gynecology (OB/GYN) specialist.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 30, 2020 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the treatment provided was medically necessary. You also say that these visits are not pre-scheduled and therefore an authorization was not obtained prior to the services being provided. The Plan denied your request. The Plan says the services were rendered by a non-participating provider. The Plan also says that prior 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 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 subsequent nursing facility care provided on
November 30, 2020 by an OON provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH is medically necessary for the enrollee's care and she meets the criteria for LTACH placement. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that are not available at the health care setting being offered by the Plan. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided on February 1, 2021, and February 2, 2021.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you should only owe a $350 inpatient copayment. 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 $20 copayment for outpatient rehabilitation services. The record shows that you received outpatient rehabilitation services on February 1, 2021, and February 2, 2021, during an outpatient hospital stay. Therefore, you are responsible to pay a $20 copayment per each
outpatient rehabilitation service. The total amount you owe is: $40. You have been asked to pay the total copayment amount of $40 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayments for outpatient rehabilitation services provided on February 1, 2021, and February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on January 20, 2021.
You asked the Plan to waive the coinsurance for DME. You say that the charges are incorrect and you should not owe anything for the DME. 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 DME and related supplies. You received DME on January 20, 2021. The total allowed amount is $180 and 20% of that is $36. You have been asked to pay the total coinsurance amount of $36 for DME. DME falls within the DME and
related 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 coinsurance for DME provided on January 20, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide acute inpatient hospital care.
You asked the Plan to provide acute inpatient hospital care. You say that the enrollee needs inpatient services. The Plan denied your request. The Plan says the enrollee did not require inpatient admission.
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 provide acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient services are met in this case.
Our physician reviewer found in this case, the record indicates that the enrollee presented with left sided pain
originally recorded as of one day duration but later consistently recorded as six months duration. The enrollee
also has chronic medical problems including dialysis dependency. The initial testing and imaging were
unremarkable. The record at the time of admission does not indicate the treating physician's reasonable
expectation of a length of stay spanning 2 or more midnights. The elements of the coverage rule are not
satisfied. The requested service cannot be recommended.
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 provide acute inpatient hospital care.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transport (A0427) provided on October 17, 2019.

You asked the Plan to pay for the ground mileage and emergency ambulance transport. You say that this claim was denied in error and needs to be reprocessed for payment. 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 ground mileage (A0425) and emergency ambulance transport (A0427) provided on October 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture - resin base (D5212) received February 25, 2021, from the out-of-network provider.

You asked the Plan to pay for the mandibular partial denture. You say that you wanted to go to the out-of-network provider because he has reasonable prices and good service. The Plan denied your request. The Plan says you must visit a participating dental network provider to receive 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 when they are received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the mandibular partial denture - resin base (D5212) received February 25, 2021, from the out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81455) provided on March 8, 2021.
You asked the Plan to pay for genetic testing. You say that this is a payable code. The Plan denied your request. The Plan says this code is non-covered.
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under CPT code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. We looked at the file and Medicare rules. The testing at issue is considered not medically necessary. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81455) provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided March 1, 2021.

You asked the Plan to waive the coinsurance for the tooth extractions. You say that you disagree with the amount the Plan paid for the services. The Plan denied your request. The Plan says the coinsurance was applied correctly.

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 extractions when the services are medically necessary and reasonable. 

We looked at the file and Medicare rules. You have been asked to pay 50% coinsurance for the tooth extractions. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the drugs or medicaments (D9630) provided from August 28, 2019, to September 5, 2019.

You asked the Plan to pay the in network rate for the limited oral evaluation, periapical x-ray. You say that you went to the dentist with 1 very loose tooth that you could not pull on your own.

You say that you paid a $50 copayment. You say that you received a bill for another $90. You also say that you do not understand the additional date of service at a different office. The Plan denied your request. The Plan says that the claims were processed correctly. The Plan says that limited oral evaluation, periapical x-ray, and drugs or medicaments are not listed as covered services. The Plan says that the dental office changed their name between the dates of service. The Plan also says that the services in this case were performed on 2 different dates of service.

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 limited oral evaluation, periapical x-ray, and drugs or medicaments are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the drugs or medicaments (D9630) provided from August 28, 2019, to September 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 4, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met.
We looked at the file and Medicare rules. The records show that the enrollee does not check blood sugar levels and adjust insulin dosage based on the results. 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 pre-approve a continuous glucose monitor (CGM).