Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care services provided from January
31, 2020, to February 2, 2020.
You asked the Plan to pay for the inpatient services. You say that you request an overturn of this denial and full
reimbursement for this original claim which includes a valid diagnosis of acute respiratory failure. The Plan
denied your request. The Plan says the removal of the diagnosis code and change in DRG is based on lack of
supporting clinical evidence from the medical record provided. Review supports DRG 195.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG. DRG 193 is defined as simple
pneumonia and pleurisy with MCC.
In this case, you billed the services provided from January 31, 2020, to February 2, 2020 with DRG 193. 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 inpatient services. Our reviewer says that
the records do not support DRG of 193. Our physician reviewer found it was noted that the physician
documented acute respiratory failure in the medical record. The medical record is examined for consistent
documentation of the condition and clinical evidence supporting the diagnosis. While the enrollee's
presentation warranted consideration of acute respiratory failure as possible diagnosis, there was no evidence of
PaCO2 > 50 mm/Hg or PaO2 < 60. The removal of the diagnosis code and change in DRG is based on lack of
supporting clinical evidence from the medical record provided and not based solely on coding guidelines.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate DRG 193. Therefore, we decided that the Plan does not have to pay for the
inpatient hospital care services provided from January 31, 2020, to February 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the knee surgery provide by the outpatient hospital facility.
You asked the Plan to waive the coinsurance for the knee surgery. You say that the services should be covered because you received authorization. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 surgery performed at an in-network outpatient hospital facility. You have been asked to pay $2,297.26 which is 20% of the allowed amount for the knee surgery. The allowed amount is $11,486.30. ($11,486.30 x 20% = $2,297.26). The knee surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 knee surgery provided by the outpatient hospital facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by a chiropractor on November 13, 2020.
You asked the Plan to pay for the office visit provided by a chiropractor. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
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 the office visit provided by a chiropractor on November 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure and two core buildups, including
any pins when required provided on June 23, 2020.
You asked the Plan to pay for the preventive procedure and core buildups. You say that you were told that
these services were approved. The Plan denied your request. The Plan says these services are not covered. The
Plan also says that you did not contact the Plan to verify benefits prior to this date of service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the 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
preventive procedure and two core buildups, including any pins when required provided on June 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided to the enrollee on September 8, 2020.
You asked the Plan to pay for the ambulance transport. You say that that a physician's office is a valid destination. The Plan denied your request. The Plan says that information provided at the time of the appeal does not support ambulance transport.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance transport. Our reviewer says that the ambulance transport was not medically reasonable and necessary for the enrollee. The documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee. The documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for the ambulance transport. 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 ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transport provided to the enrollee on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2330) provided on October 13, 2020.
You asked the Plan to pay for the dental service. You say that you feel that people should be able to use any
doctor that they chose. You say that you would like the services to be covered. The Plan denied your request.
The Plan says the provider in this case is out-of-network. The Plan also says that dental services that care
rendered by a provider that is not part of our supplemental dental network 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 filling
(D2330) provided on October 13, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the drugs (J8499) you were provided on November 21, 2020.
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says that this is not a covered
service.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were provided for the drugs by a contract provider. The file does not show that the Plan provided notice
that the drugs would not be covered. Under Medicare rules, this means the drugs is considered approved by the
Plan. You received the drugs with the reasonable expectation that they would be covered under your plan.
Therefore, we decided that the Plan has to pay for the drugs (J8499) you were provided on November 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120), prophylaxis (D1110), and the
bitewing x-rays (D0274) provided on May 1, 2019.
You asked the Plan to pay for the dental services. You say that your dentist did not say anything about
insurance at the time you received the services. You say that you were not aware that you had dental coverage
until 2020. You also say that you had a lot of medical issues in 2019. The Plan denied your request. The Plan
says no payment for services or supplies if a claim for such has not been received by the dental plan within 1
year following the date the services or supplies were completed.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the dental services was not filed until October 30, 2020. This means that
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for the oral evaluation (D0120), prophylaxis (D1110), and the
bitewing x-rays (D0274) provided on May 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Ascent injection.
You asked the Plan to pre-approve the injection. You say that other pain reduction methods have not worked. The Plan denied your request. The Plan says this is an experimental/investigational drug. Therefore, it is deemed not medically reasonable or necessary.
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 the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational drug. Therefore, it is deemed not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve the Ascent injection.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on January 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the lab testing. You say that you were referred to by another provider and did not have time to get prior authorization. The Plan denied your request. The Plan says they do not cover out of network care, except in limited circumstances. The services were not urgent, the provider who is listed as the referring provider is not contracted with the Plan, and prior authorization could have been requested by either party at any time prior to the date of service.
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 lab testing services provided on January 15, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
You asked the Plan to pre-approve the MRI. You say that the records provided support the need for the requested MRI. The Plan denied your request. The Plan says they did not receive the results of the exam done showing a reason that the requested study is needed.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found the medical records provided show that the enrollee was hit by a car on October 1, 2020. He was seen by the provider on February 8, 2021, for neck pain and bilateral upper extremity pain and numbness. The enrollee has been treated with Tylenol 3 and diclofenac. He participated in physical therapy. The CPT code requested was 70450, which represents an MRI of the soft tissue neck and not of the cervical spine. The records provided do not demonstrate that an MRI of the soft tissue neck is appropriate or medically reasonable in this case. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
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 you need rehabilitation after breaking your hip. The Plan denied your request. The Plan says you can be treated at a lower level of care.
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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a lower level of care. There is not a reasonable expectation that you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for oncology gene expression profile testing (CxBladder Monitor) provided on August 12, 2020.
You asked the Plan to pay for genetic testing. You say that this testing is eligible for payment and was medically necessary. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this test was not covered for the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that oncology gene expression profile testing was not covered by MolDX for date of service August 12, 2020. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for oncology gene expression profile testing (CxBladder Monitor) provided on August 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance for the outpatient surgery provided on October 14, 2020.
You asked the Plan to adjust the coinsurance for the knee surgery. You say that you were under the impression that the provider would bill an inpatient copayment. The Plan denied your request. The Plan says you were charged the copayment correctly for the outpatient surgery.
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 Outpatient Surgery. You have been asked to pay 20% coinsurance for the knee surgery. The knee surgery falls within the Outpatient Surgery 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 adjust the coinsurance for the outpatient surgery provided on October 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided to the enrollee on October 22, 2020.
You asked the Plan to pay for the ambulance transport. You say that these services were medically necessary. The Plan denied your request. The Plan says that information provided at the time of the appeal does not support ambulance transport.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance transport. Our reviewer says that the ambulance transport was not medically reasonable and necessary for the enrollee. The documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient. The documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for the ambulance transport. 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 ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transport provided to the enrollee on October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3320) provided on November 10, 2020.
You asked the Plan to pay for the dental service. You say that you are a retired veteran. You say that you live on a fixed income. You also say that your teeth are broken, making it hard to eat. The Plan denied your request. The Plan says there is a maximum payment of $800 per person total per benefit year on all 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 maximum payment of $800 for dental services has been exceeded.
Therefore, we decided that the Plan does not have to pay for the root canal (D3320) provided on November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on October 26, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you cannot afford to pay for this. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that no benefits are available for procedures performed by OON providers.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on October 26, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care and wound care services provided by an out-of-network provider on September 18, 2020.
You asked the Plan to pay for the nursing facility care and wound care services. You say that a delay in care could have resulted in wound complications. You say that the services were medically necessary, and payment should be processed. The Plan denied your request. The Plan says prior authorization for out-of-network services is required.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the nursing facility care and wound care services provided by an out-of-network provider on September 18, 2020.