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

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a panoramic
radiographic image (D0330), and oral surgery services (D7210, D7921, D9223, D9222, D7922).

You asked the Plan to pay for a limited oral evaluation, a panoramic radiographic image, and oral surgery
services. You say that you do not understand why these services are not covered. The Plan denied your request.
The Plan says the panoramic image and oral surgery services are not covered per your dental benefits and the
oral evaluation denied correctly as exceeding the frequency limit for this 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, panoramic radiographic images and
oral surgery services are not a covered benefit. At the time of service, you had exceeded the benefit limit of two
oral examinations per year. Therefore, we decided that the Plan does not have to pay for a limited oral
evaluation (D0140), and a panoramic radiographic image (D0330), and oral surgery services 
(D7210, D7921, D9223, D9222, D7922).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the knee injections you received on September 14, 2020.
You asked the Plan to waive the cost share for the services provided. You say that you received this service in 2017 and was not charged. The Plan denied your request. The Plan says the claim was processed 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% coinsurance for Medicare Part B prescription drugs. The file shows that you received Synvisc injections. You have been asked to pay a 20% coinsurance for the services provided. The services 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 cost share for the knee injections you received on September 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the physical therapy services provided from August 20, 2020, to November 30, 2020.
You asked the Plan to waive the cost shares for the services provided. The Plan denied your request. The Plan says the claim processed 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 40% coinsurance for each Medicare-covered out-of-network visit for outpatient rehab services. You have been asked to pay a 40% coinsurance for the services provided. The services fall within the outpatient rehab 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 cost shares for the physical therapy services provided from August 20, 2020, to November 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on October 24, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that your primary care doctor made the decision for you to have a CT scan. You say that you are not able to pay for this service. The Plan denied your request. The Plan says the copayment applied 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 $225 copayment for CT scans performed by an in-network provider other than your primary care physician. You have been asked to pay $110.27, which is less than the standard $225 copayment for the CT scan. The CT scan 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 CT scan provided on October 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, the health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform/tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care evaluation services coded 99291 provided on September 12, 2020.
You asked the Plan to pay for the critical care evaluation 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 separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Review of the file shows that for the critical care services to be paid, the services must be reported with modifier 25 to indicate that this service was a separately identifiable service from the smoking and tobacco cessation services coded 99407 provided on the same date. The critical care services were not billed with the appropriate modifier. This means that this code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the critical care evaluation services coded 99291 provided on September 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist services provided on November 7,
2020.
You asked the Plan to waive the copay for the specialist services. You say that you were kept in observation for
several days. The Plan denied your request. The Plan says you were not an inpatient at the time of service.
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
copay for each visit or consultation in an outpatient location with a specialist.
You have been asked to pay a $40 copay for the specialist services. The services fall within the physician
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 copay for the specialist services provided
on November 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and psychotherapy (90836) provided on October 12, 2020.
You asked the Plan to pay for the office visit and psychotherapy. You say that you would like reconsideration because you paid for these services in full and payment was sent to the provider instead of you. The Plan denied your request. The Plan says services performed by a privately contracted provider are not covered.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visit (99214) and psychotherapy (90836) provided on October 12, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy provided by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy. You say that you were told all visits, testing, and treatments were covered. The Plan denied your request. The Plan says no prior authorization was 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 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the acute care hospital on 3/21/21 with fatigue and a non-ST elevation myocardial infarction. Conservative management was advised by cardiology. It is noted that the enrollee is basically bed-bound and incontinent. It has become very difficult to care for the enrollee at home. On 3/25/21 it is documented that the enrollee is very confused, lethargic, and easily agitated. The enrollee's dementia is documented to be "advanced, potentially end-stage." Based on the documentation provided, the enrollee does not require skilled nursing or skilled therapy services on a daily basis. While the enrollee may benefit from short-term skilled physical therapy, the documentation does not support the need for skilled therapy services on a daily basis in an inpatient setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Medicare Part B prescription drug provided on October 30, 2020.
You asked the Plan to waive the coinsurance for the Medicare Part B prescription drug. You say that you never received this service. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance of the Medicare-approved amount for Medicare Part B prescription drugs. The allowed amount of this drug is $782.19, however; you have only been asked to pay $140.50 which is less than 20% coinsurance for this drug. You have been asked to pay 20% coinsurance of the Medicare-approved amount for the Medicare Part B prescription drug. Medicare Part B prescription drugs falls 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 the Medicare Part B prescription drug provided on October 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, the health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you do not show to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance supplies provided on October 6, 2020.
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says this is included in the transport fee.
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the general ambulance service and payment for them is included in the payment rate for the transport. We looked at the file and Medicare rules. Payment for the requested ambulance supplies is included in the payment for the ambulance transport. Supplies are not separately payable. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance supplies provided on October 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs that were provided during an
inpatient hospital stay.

You asked the Plan to pay for the self-administered drugs. You say that the services provided in the hospital
were medically necessary and question why the medication you were given is not being covered. The Plan
denied your request. The Plan says the services in dispute are not covered by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self administered
drugs. The drugs provided do you during your inpatient hospital stay are drugs that are usually
self-administered by the patients who take them. The self-administered drugs that were provided to you while
in the hospital are not among the types which are covered by Medicare Part B. Therefore, we decided that the
Plan does not have to pay for self-administered drugs that were provided during an inpatient hospital stay.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (98941, 97110, 98940, 99201) provided on September 22, 2020 to November 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON chiropractic services. You say that you were not told you needed a referral. The Plan denied your request. The Plan says these 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 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 chiropractic services (98941, 97110, 98940, 99201) provided on September 22, 2020 to November 6, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel SureClick.
You asked the Plan to pre-approve Enbrel SureClick. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Enbrel SureClick is not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Enbrel SureClick.
Benefits for Enbrel SureClick may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital services you received from January 12, 2020, to January 21, 2020, and the computed tomography (CT) scan you had on October 10, 2020.
You asked the Plan to waive the copayments for the inpatient hospital services and the CT scan. You say that you were unaware of these copayment amounts because you thought you should not have to pay anything if your qualified for extra benefits. The Plan denied your request. The Plan says you were charged these copayments 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 $295 copayment per day for days 1-6 and a $0 copayment per day for days 7-90 for inpatient hospital care as well as a $225 copayment for diagnostic radiology services. Records show that you were in the hospital as an inpatient for ten days. You have been asked to pay a $295 copayment per day for days 1-6 and a $0 copayment per day for the remainder of the stay for the inpatient hospital services you received. In addition, you have been asked to pay a $225 copayment for the CT scan. This means that you have been asked to pay the correct amounts 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 the inpatient hospital services you received from January 12, 2020, to January 21, 2020, and the computed tomography (CT) scan you had on October 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve periodontal scaling and root planing of four or more teeth (D4341) to be provided for the lower left, lower right, and upper right quadrants.
You asked the Plan to approve the periodontal scaling and root planing. You say that the Plan was reviewing the x-rays from the wrong provider, and there is enough bone loss according to your dental provider. The Plan denied your request. The Plan says there is not sufficient bone loss for approval of this 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. The Plan covers the periodontal scaling and root planing when the services are medically necessary and reasonable. 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 approve the periodontal scaling and root planing. Our reviewer says that periodontal scaling and root planing of four or more teeth is not supported as medically necessary for the three requested quadrants. Our physician reviewer found that the Plan requirements state that the following is required: "A minimum of four teeth affected in the quadrant. Periodontal charting indicating abnormal pocket depths in multiple sites. Additionally, at least one of the following must be present: 1) Radiographic evidence of root surface calculus. 2) Radiographic evidence of noticeable loss of bone support."
In this instance, the provided x-rays show limited views of any quadrant, only showing the supra bony distal aspect of teeth 11 and 28, and a distorted view of the lower left quadrant. The lower left quadrant does not show any bone loss, and the bone levels cannot be seen on the supplied x-rays in the other two quadrants. The lack of ability to visualize the bone on radiographs prevents full assessment of the periodontal condition. Given the supplied information, there can be no finding of medical necessity for the requested scaling and root planing of the lower left, lower right, and upper right quadrants. We looked at this physician's review, the file, and Medicare rules. You stated that there were other x-rays to view in this case, but these were not provided or included in the record. Based on the provided information, we decided that the Plan's rules for coverage of the periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to approve periodontal scaling and root planing of four or more teeth (D4341) to be provided for the lower left, lower right, and upper right quadrants.