Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the diagnostic testing and therapy services
provided on November 27, 2019.
You asked the Plan to waive the copays for the services provided. You say that a full evaluation was not done.
The Plan denied your request. The Plan says if you have more than one type of therapy during the same visit, a
cost-sharing will apply to each type.
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 file shows that you received a throat x-ray. A $20 copay was applied. The service falls within the
outpatient diagnostic tests benefit category. A motion fluoroscopic evaluation was provided. A $40 copay was
applied. The service falls within the outpatient rehab services benefit category.
The Plan contract says that you pay a copay each time you receive certain medical services. 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 copays for the diagnostic testing and therapy services provided on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 8, 2018 by an out of
network (OON) provider.
You asked the Plan to pay for these services. You say that you didn't realize the provider was out-of-network.
The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without
prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on August 8, 2018
by an out of network (OON) provider.
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. The Plan denied your request. The Plan says the enrollee does not have a complex medical condition that needs monitoring by a physician, and does not need a multidisciplinary approach to rehab.
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 physician reviewer found that you are at contact guard assist for ambulation, independent for upper body dressing, and supervision for lower body dressing. Your renal function was stable and good. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status does not require intensive physician or nursing oversight in an IRF. You may benefit from additional multiple therapies, however your high functional level in combination with your endurance deficits do not require or indicate that this therapy must be in an IRF with an intensive level program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for emergency room services provided on November 6, 2019.
You asked the Plan to pay for emergency care. You say that this emergency room visit was not for dental but for a severe infection. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this service was a non-covered dental service.
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for emergency room services provided on November 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), the prophylaxis (D1110), and the
implants (D6010) provided from February 12, 2019 to August 20, 2019 by an out of network provider.
You asked the Plan to pay for the oral exam, prophylaxis and implant. You say that you did not know that you
had dental insurance until recently. You also say that a plan representative advised the provider was out of
network and would be paid accordingly. The Plan denied your request. The Plan says dental services that you
receive out of network are not covered. The Plan also says that implants are not 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 and the oral exam and prophylaxis are
listed as covered services, they are not covered when you receive them out of network. Additionally, implants
are not listed as a covered service. Therefore, we decided that the Plan does not have to pay for the oral exam
(D0120), the prophylaxis (D1110), and the implants (D6010) provided from February 12, 2019 to August 20,
2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment and supplies provided to the enrollee on January 31, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says these charges are included in the Part A SNF payment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the services was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for durable medical equipment and supplies provided to the enrollee on January 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an excision (25111) provided on February 28, 2019.
You asked the Plan to pay for the excision. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the documentation does not support the billed service.
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 25111 is excision of ganglion, wrist (dorsal or volar);
primary.
We asked our coder 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 excision. Our reviewer says that CPT code 25111 does
not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided
do not include documentation of an excision of ganglion, wrist (dorsal or volar); primary being performed on
February 28, 2019, therefore this service cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the excision have not been met. Therefore, we decided that the Plan does not
have to pay for an excision (25111) provided on February 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for two ultrasounds (76641) provided January 13, 2020.
You asked the Plan to waive the copayments for the ultrasounds. You say that the copayment should only be $125. The Plan denied your request. The Plan says the correct copayments were 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 $125 copayment for Radiological Diagnostic services. You have been asked to pay a $119.07 copayment for each ultrasound. The Medicare allowed amount is less than the $125 stipulated in the plan contract. 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 two ultrasounds (76641) provided January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia (D9222) and the therapeutic parenteral drug (D9610) provided on January 28, 2020.
You asked the Plan to pay for the dental services. You say that the enrollee needed the sedation to successfully remove tooth # 3 without complications. You say that the tooth was causing her pain and infection. You also say that without the sedation, the enrollee would have had a severe panic attack which would have hindered any necessary treatment. The Plan denied your request. The Plan says the anesthesia and therapeutic parenteral drug that the enrollee received are not listed as covered dental services.
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 anesthesia and the therapeutic parenternal drug are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the anesthesia (D9222) and the therapeutic parenteral drug (D9610) provided on January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental surgery procedures, alveoloplasties, surgical placement of implant bodies: endosteal implants, additional extractions, first 15 minutes of deep sedation/general anesthesia, and each subsequent 15 minute increment of deep sedation/general anesthesia provided on October 9, 2019 and November 14, 2019.
You asked the Plan to pay for the dental surgery procedure, alveoloplasty, endosteal implant, and additional extractions. You say that these services are a continuation of a problem you had in 2019. You also say that these services were done so you could maintain a balanced and healthy diet. The Plan denied your request. The Plan says these 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, dental surgery procedure, alveoloplasty, and surgical placement of implant body: endosteal implant are not among those covered under this benefit. The contract clearly states that extractions are limited to two procedures per calendar year. The record shows that you received multiple extractions on October 9, 2019, the Plan paid for two of the extractions, and your extractions benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the dental surgery procedures, alveoloplasties, surgical placement of implant bodies: endosteal implants, additional extractions, first 15 minutes of deep sedation/general anesthesia, and each subsequent 15 minute increment of deep sedation/general anesthesia provided on October 9, 2019 and November 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin and oxygen care, and daily therapy can be provided at a SNF. In this case, you are mostly minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained in a predicted and reasonable period. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99204), extraspinal manipulation (98943), and therapeutic services (97535, 97110, 97012, and G0283) provided on January 2, 2020.
You asked the Plan to pay for a chiropractic office visit, extraspinal manipulation, and therapeutic services. You say that these services should have been covered. The Plan denied your request. The Plan says neither Medicare nor the Plan covers these services.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for a chiropractic office visit (99204), extraspinal manipulation (98943), and therapeutic services (97535, 97110, 97012, and G0283) provided on January 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for air travel transportation provided on August 10,
2019.
You asked the Plan to reimburse you for the non-emergent air travel expense. You say that under the Passport
Program you were approved to see a specialist so your plane and auto expenses should be covered. The Plan
denied your request. The Plan says lodging and transportation costs are covered only for transplant patients.
The Plan must follow Medicare rules. Medicare rules say that if you get services that are excluded you must
pay for them yourself.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of air travel have not been met. You are not a transplant patient. Therefore, we decided that the Plan
does not have to reimburse you for air travel transportation provided on August 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for osteopathic manipulation of the spine (98928) provided on October 22, 2019.
You asked the Plan to pay for the osteopathic manipulation. You say that you would like reconsideration because manipulation of the spine is a covered benefit. The Plan denied your request. The Plan says the service is not allowed under the applicable client summary and therefore is not eligible for reimbursement according to the provider's contract.
The rules say that Medicare does not cover the services of a naturopath. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays for routine (non-Medicare covered) chiropractic services, acupuncture and naturopathy. We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the osteopathic manipulation have not been met. Osteopathic manipulation of the spine is not a covered service under the Plan. Additionally, the record indicates that you signed a non-covered services consent form. Therefore, we decided that the Plan does not have to pay for osteopathic manipulation of the spine (98928) provided on October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction services (92015) provided February 4, 2020.
You asked the Plan to pay for the refraction services. You say that the plan denied payment to the eye doctor and you have always had some pay to the doctor. The Plan denied your request. The Plan says this service is not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when eye refraction is not covered under the plan benefits.. We looked at the file and the Plan's rules. Eye refraction services is not covered under the plan benefits. Based on this information, we decided that the Plan's rules for coverage of the refraction services have not been met. Therefore, we decided that the Plan does not have to pay for refraction services (92015) provided February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 6,
2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you should only owe a $20
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 $45
copayment for each specialist visit.
The record shows that you received services from a specialist on January 6, 2020. Therefore, you are
responsible to pay the $45 copayment.
You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits 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 specialist visit provided on January 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 19, 2019.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that 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 $325 copayment for each Medicare-covered one-way ambulance trip. You have been asked to pay a $325 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered one-way ambulance trip 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 ambulance transport provided on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, additional
intraoral periapical x-ray, resin-based composite, complete series of intraoral x-rays, comprehensive oral
evaluation, and scaling in presence of generalized moderate or severe gingival inflammation provided on
October 29, 2019 to November 7, 2019 by an OON provider.
You asked the Plan to pay for the problem focused limited oral evaluation, intraoral periapical x-rays, resinbased
composite, comprehensive oral evaluation, and scaling. You say that a Plan representative told the
provider's office that you had coverage for the work you needed done. The Plan denied your request. The Plan
says no benefits are available for procedures performed by OON providers or outside of the providers
contracted period.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
covered when they are received OON. The Plan confirmed that the call records do not support that you, nor the
provider's office, contacted the Plan to verify your benefits or the provider's network status prior to the services
being rendered. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral
evaluation, additional intraoral periapical x-ray, resin-based composite, complete series of intraoral x-rays,
comprehensive oral evaluation, and scaling in presence of generalized moderate or severe gingival
inflammation provided on October 29, 2019 to November 7, 2019 by an OON provider.