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

We decided that the Plan does not have to pay for the complete series x-ray (D0210) and the adjunctive pre-diagnostic test (D0431).

You asked the Plan to pay for the dental services. You say that prior to making your appointment, you inquired as to whether the provider accepted your plan. You say that all you wanted was a cleaning and expected a basic x-ray and exam as well. You say that you were advised you would need additional, non-covered, services. You say that you were not advised of a copayment or any type of money that you owed. You say that you received a bill for $168. You also say that you feel that you were taken advantage of and not advised of your options prior to the exam. The Plan denied your request. The Plan says the complete series x-ray is not listed as a covered service. The Plan says adjunctive pre-diagnostic test is not listed as a covered service. The Plan also says you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

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 complete series x-ray (D0210) and the adjunctive pre-diagnostic test (D0431).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 13, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the physician services. You say that the medically necessary services were provided to the enrollee in good faith. The Plan denied your request. The Plan says authorization was not obtained prior to the services being rendered to the enrollee. The Plan also says that it is the provider's responsibility to verify the enrollee's current eligibility and authorization requirements prior to the services being rendered to the enrollee.

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 provider in this case is not a network provider with the Plan. The referring facility is not in network either. The Plan did not pre-approve the service 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 medical services provided on July 13, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on September 16, 2020.

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 procedure code 99223 is not covered.

The Plan must follow Medicare rules. The rules say that when a patient has been admitted to inpatient hospital care for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date, Observation or Inpatient Hospital Care Services (Including Admission and Discharge Services), from CPT code range 99234 - 99236, shall be reported. 

We looked at the file and Medicare rules. The file shows that observation code 99217 was paid on the subsequent date from the inpatient services at issue. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care rendered on September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on October 6, 2020.

You asked the Plan to pay for the dental services. You say that you fractured your bridgework while you were eating. You say that the extent of the damage could not be seen without a dental exam. You also say that the dental services were the result of an accident and not a routine dental cleaning or annual check-up. The Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. The Plan also says that the periapical x-ray is not listed as a covered service either.

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 limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on October 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy visits provided from September 1, 2020, to October 22, 2020.

You asked the Plan to waive the copayments for the physical therapy visits. You say that your doctor referred you so there should be no copay charge. The Plan denied your request. The Plan says you were charged the 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 $25 copayment for Outpatient Rehabilitation Services. 

You have been asked to pay a $25 copayment for the physical therapy visits. The physical therapy visits 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. The Annual Notice of Changes documentation you submitted is for a different contract, not for your plan. Therefore, we decided that the Plan does not have to waive the copayments for physical therapy visits provided from September 1, 2020, to October 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 13, 2020,
to August 31, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's
condition no longer required daily skilled services at an inpatient SNF level of care.
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 skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from August 13, 2020, to August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dexamethasone sodium phosphate injection,
fosaprepitant injection, magnesium sulfate injection, Dexamethasone, cisplatin injection, gemcitabine
hydrochloride injection, paclitaxel protein-bound particles injection, and Ondansetron.
You asked the Plan to pre-approve dexamethasone sodium phosphate injection, fosaprepitant injection,
magnesium sulfate injection, Dexamethasone, cisplatin injection, gemcitabine hydrochloride injection,
paclitaxel protein-bound particles injection, and Ondansetron. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are part of routine
costs in a clinical trial.
The Plan must follow Medicare rules. Medicare rules say that routine costs related to a clinical trial are noncovered.
We looked at the file and Medicare rules. Review of the file shows that the enrollee is enrolled in a clinical
trial. The requested services are considered routine costs for the clinical trial. Based on this information, we
decided that Medicare rules for coverage of dexamethasone sodium phosphate injection, fosaprepitant
injection, magnesium sulfate injection, Dexamethasone, cisplatin injection, gemcitabine hydrochloride
injection, paclitaxel protein-bound particles injection, and Ondansetron have not been met. Therefore, we
decided that the Plan does not have to pre-approve dexamethasone sodium phosphate injection, fosaprepitant
injection, magnesium sulfate injection, Dexamethasone, cisplatin injection, gemcitabine hydrochloride
injection, paclitaxel protein-bound particles injection, and Ondansetron.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the aminophylline injection services coded J0280 provided
on August 24, 2020.
You asked the Plan to pay for the aminophylline injection 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 supported by the
documentation.
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 J0280 is injection, aminophylline, up to 250 mg.
We find that CPT code J0280 is not supported in the medical record. Specifically, the documentation submitted
did not support that aminophylline injection, up to 250 mg was administered on the billed date of service.
Based on this information, we decided that Medicare rules for coverage of the aminophylline injection services
have not been met. Therefore, we decided that the Plan does not have to pay for the aminophylline injection
services coded J0280 provided on August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on October 12, 2020.You asked the Plan to pay forthe dental services. You say that dental exams are covered. You say that you were having pain while chewing. You say that you wanted to see if you needed a root canal.The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that periapical x-ray is not listed as a covered service either.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. Additionally, the record shows that you are not enrolled in the optional supplemental dental benefit.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on October 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on September 3, 2020.
You asked the Plan to pay for a CT scan. You say that this service is not specific to a place of service. The Plan denied your request. The Plan says this was not billed with the correct place of service.
The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. We looked at the file and Medicare rules. The services at issue were reported with POS 22 for an outpatient hospital, but the record shows that the enrollee was registered as an inpatient at the time of service. Based on this information, we decided that Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on September 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical and infertility services provided on August 18, 2020.

You asked the Plan to pay for the surgical and infertility services. The Plan denied your request. The Plan says your Plan does not have out-of-network benefits.

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 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 surgical and infertility services provided on August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem-focused oral exam you received.

You asked the Plan to pay for the exam. The Plan denied your request. The Plan says this is not a covered benefit.

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 services are not among those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage. While the Plan does cover periodic oral exams, problem-focused oral exams are not covered. Therefore, we decided that the Plan does not have to pay for the problem-focused oral exam you received.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0998).

You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The Plan denied your request. The Plan says ambulance services are not covered when there is no transport.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance services (A0998).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the arthrocentesis.

You asked the Plan to waive the copayments for arthrocentesis (20610). You say that you were told the shots were covered but not informed your responsibility would be $709.35. The Plan denied your request. The Plan says you were charged the 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 for Outpatient Surgery.

You have been asked to pay a $236.45 copayment for each arthrocentesis (20610). Arthrocentesis (20610) falls within the Outpatient Surgery benefit category. The copayment is less because the allowed amount is less than your copayment. 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 the arthrocentesis.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on November 4, 2020.

You asked the Plan to pay for the radiology services. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says the records supports 1 unit of each procedure which were previously paid.

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 codes 73522, 72110, 73564 are not supported in the medical record. Specifically, the records support one unit of each and the services were already paid for. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services provided on November 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating
provider on October 19, 2020.
You asked the Plan to waive the copayment for lab work. You say that you went for your annual exam and had
blood work done. You say that you do not think you should have to pay for this. The Plan denied your request.
The Plan says the correct copayment has been applied.
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 $5
copayment for outpatient diagnostic tests/laboratory tests.
You have been asked to pay a $5 copayment for lab work. When additional services are provided during an
annual wellness exam, additional copayments can be applied; therefore, the correct copayment has been
applied. Lab work falls within the outpatient diagnostic tests/laboratory tests 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 lab work provided by a participating provider on October 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.

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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about the enrollee's condition the enrollee does not meet the requirements for an IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a wound infection after recent below the knee amputation. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services (73502, 73030, 73552, 73060, 73063) provided on October 1, 2020.
You asked the Plan to pay for the imaging services. The Plan denied your request. The Plan says only one unit of each code is supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that additional units of CPT codes 73502, 73030, 73552, 73060 and 73063, are not supported in the medical record. Specifically, the records show that only one unit of each code was provided on the date of service in question. The Plan processed and paid for one unit of each code. Based on this information, we decided that Medicare rules for coverage of the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for the imaging services (73502, 73030, 73552, 73060, 73063) provided on October 1, 2020.