Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214, 82962) provided on October 19, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for an OON office visit. You say that the provider has been trying to enroll with the Plan. The Plan denied your request. The Plan says this was 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 an office visit (99214, 82962) provided on October 19, 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 the requested physician's services.

You asked the Plan to pre-approve the physician's services. You say that you were under the care of this
physician for a consultation on September 2, 2020 for suspected glaucoma and nuclear sclerotic cataract of
right eye. The Plan denied your request. The Plan says the records do not show that your care requires highly
specialized providers or that your care cannot be well-managed by a community specialist.

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 physician's services to be provided by
the requested physician services. Our reviewer says that the requested physician's services are not considered
medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that
you were seen by the requested physician one year ago with routine follow up ordered but no treatment. You
wish to go to the requested provider due to proximity. The record does not establish the medical reasonableness
or necessity, as defined by Medicare rules of the requested service. The elements of the coverage criteria 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 physician's services to be provided by the requested physician have not been
met. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Initial and subsequent hospital visit (99231) provided December 22, 2020 to December 26, 2020.
You asked the Plan to pay for the hospital visit. You say that you are requesting reconsideration of payment for initial hospital care per day. The Plan denied your request. The Plan says missing patient medical record for this service. The records do not support the services provided.
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 99231 is inpatient hospital visits: initial and subsequent, per day. We find that CPT code 99231 is not supported in the medical record. Specifically, records are still needed to support the service 99231. The records show that the Plan made multiple attempts to obtain the additional information from the provider without success. Based on this information, we decided that Medicare rules for coverage of the hospital visit have not been met. Therefore, we decided that the Plan does not have to pay for Initial and subsequent hospital visit (99231) provided December 22, 2020 to December 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on November 11, 2020 and
November 25, 2020.
You asked the Plan to pay for the dental services. You say that you contacted the Plan to figure out a covered
dentist prior to scheduling an appointment. You say that you were informed the dentist was included in the
Plan. The Plan denied your request. The Plan says out-of-network dental services are not covered 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, out-of-network dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental
services provided on November 11, 2020 and November 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81404, 81479) provided December 30, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is non-covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular-respiratory disease. 

We looked at the file and Medicare rules. The service at issue is cardiovascular risk assessment testing. This service is not covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81404, 81479) provided December 30, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient hospital services for the enrollee.

You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that that inpatient level of care is not necessary.

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 pre-approve inpatient hospital services. Our reviewer says that inpatient hospital services are medically reasonable and necessary for the enrollee. You are seeking to electively admit the enrollee for Dihydroergotamine (DHE) infusions. The proposed course of treatment generally lasts beyond two midnights in duration (patients usually stay for a few days until a migraine headache cycle is "broken"). Our physician reviewer found that the enrollee's condition meets criteria for coverage of inpatient hospital services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital services have been met. Therefore, we decided that the Plan has to pre-approve inpatient hospital services for the enrollee.

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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services rendered on January 18, 2021 to January 26, 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 that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided a clear explanation as to why the services at issue are not covered. There is no documentation or Medicare rules referenced to support that the services are not covered. Therefore, we decided that the Plan has to pay for the services rendered on January 18, 2021 to January 26, 2021.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency room services (99217) provided November 30, 2020.

You asked the Plan to pay for the Emergency room services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 99217 is not supported in the medical record. Specifically, Z590 is not a valid primary diagnosis as it describes no symptoms or condition that would necessitate the service. Based on this information, we decided that Medicare rules for coverage of the Emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for Emergency room services (99217) provided November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on February 5, 2021.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you were not aware the charges would be so high and cannot afford them. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on February 5, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $4,715.10 and 20% of that is $943.02. You have been asked to pay the total coinsurance amount of $943.02 for a Medicare Part B drug injection. A Medicare Part B drug injection 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 a Medicare Part B drug injection provided on February 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210), first 15 minutes of deep
sedation/general anesthesia (D9222), each subsequent 15 minute increment of deep sedation/general anesthesia
(D9223), and therapeutic parenteral drug (D9610) provided on January 22, 2021 by an OON provider.

You asked the Plan to pay for the extraction, deep sedation/general anesthesia, and therapeutic parenteral drug.
You say that you are in a lot of pain and think you have an infection. You also say that you would like to find
an oral surgeon with earlier availability. The Plan denied your request. The Plan says the provider is OON and
not covered by your plan.

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
covered when a prior authorization has been obtained. Therefore, we decided that the Plan does not have to pay
for the extraction (D7210), first 15 minutes of deep sedation/general anesthesia (D9222), each subsequent 15
minute increment of deep sedation/general anesthesia (D9223), and therapeutic parenteral drug (D9610)
provided on January 22, 2021 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve admission to an inpatient mental health facility for the enrollee.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that this is medically necessary. The Plan denied your request. The Plan says that treatment can happen in a lower level of care, such as outpatient treatment.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric hospital services. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee admitted with schizoaffective disorder, bipolar type. It is expected that the enrollee would improve in a reasonable period of time for the dates in question, as she did have noted suicidal ideation. There were auditory hallucinations and delusional thinking. There are symptoms that would require acute treatment. The enrollee is a danger to herself. The health plan's denial of continued inpatient psychiatric services is inappropriate.

 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pre-approve admission to an inpatient mental health facility for the enrollee.

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 complete lower denture (D5120) provided on February 22, 2021.
You asked the Plan to pay for the denture. You say that you have not used a lower denture in 15 years. You say that you have lower bone loss. You say that the denture does not stay in. You say that your dentist insisted on doing both an upper and lower denture due to bite variation. You also say that you still cannot use the lower denture because they do not stay in. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit 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 and complete lower denture is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for an immediate lower denture that you received on June 5, 2017. Therefore, we decided that the Plan does not have to pay for the complete lower denture (D5120) provided on February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on April 7, 2021.
You asked the Plan to pay for the core buildup. You say that this service should be covered because in order to have the crown the buildup needs to be placed on your tooth until the crown is ready. The Plan denied your request. The Plan says this service is 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on April 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan provided on April 22, 2021.
You asked the Plan to waive the copayment for CT scan. You say that you did not feel like having this procedure again and should be reimbursed this copayment. 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 $200 copayment for CT scan. You have been asked to pay the allowed amount of $184.11, which is less than the $200 copayment for CT scan. 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 a Computed Tomography (CT) scan provided on April 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on March 18, 2020.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says an inpatient admission was not medically necessary.
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 that the record indicates that the enrollee presented to the emergency department with a dislocated prosthetic knee. The record indicates that the admission order was cancelled shortly after being placed because the knee was successfully reduced. The record does not support that the treating physician had a reasonable expectation of a length of stay spanning 2 or more midnight because it was placed prior to the orthopedic evaluation of the enrollee. The elements of the coverage rule are not satisfied. The requested service is not 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 pay for the acute inpatient hospital care provided on March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth visit provided on January 20, 2021.

You asked the Plan to waive the copayment for a telehealth visit. You say that you should not owe a copayment for the visit and were told it would be taken care of. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment for primary care provider visits, including telehealth services. 

The enrollee has been asked to pay a $20 copayment for a telehealth visit. A telehealth visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a telehealth visit provided on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) provided on February 2, 2021.
You asked the Plan to pay for the removal of residual tooth roots. You say that you were advised that this service would be covered. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says this service is 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) provided on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 4, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 an office visit provided on September 4, 2020 by an out-of-network (OON) provider.