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

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 2, 2017, through January 4, 2017.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically necessary. The Plan denied your request. The Plan says that the services provided could have been delivered in an alternate level of care.

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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was a then 95-year-old female with a past medical history of chronic obstructive pulmonary disease, hypertension, osteoarthritis, and history of left breast cancer. She presented to the emergency department (ED) January 2, 2017due to shortness of breath for two to three days with productive cough. The enrollee had stable vitals, no respiratory distress, sodium of 159, normal troponin, and negative chest X-ray for acute pulmonary process. The enrollee was given intravenous (IV) fluids, IV Levaquin, a renal consultation, and nebulizers. Her sodium improved to 137 after IV fluids. The enrollee had stable vitals on January 3, 2017, and her creatinine improved to 0.95 from 1.05. The enrollee was discharged on January 4, 2017 in stable condition. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 2, 2017, through January 4, 2017.

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 problem focused limited oral evaluation and first intraoral periapical x-ray provided on February 16, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you feel you should not be held responsible for these services. The Plan denied your request. The Plan says these services are 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 problem focused limited oral evaluation and first intraoral periapical x-ray provided on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the administration of drugs provided from
October 6, 2020, to February 9, 2021.

You asked the Plan to waive the copayments for the administration of drugs. You say that you bring the
medication into the office and have paid less for the administration in the past. 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 specialist services.

You received the administration of drugs from October 6, 2020, to February 9, 2021, for a total of 4 services.
Therefore, you are responsible to pay $15.54 per each visit. $15.54 (allowed amount) x 4 (services) = $61.16,
which is less than the total copayment amount.

You have been asked to pay the total amount of $62.16 the administration of drugs. The administration of
drugs 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 copayments for the administration of drugs provided from October 6, 2020,
to February 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 23, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that the referring provider is out-of-network.

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 lab work provided on December 23, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingival irrigation (D4921 x2) provided on February 10,
2021.
You asked the Plan to pay for gingival irrigation. You say that you thought the service would be covered and
you want the Plan to pay. The Plan denied your request. The Plan says the service at issue 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 items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival
irrigation (D4921 x2) provided on February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a surgical procedure for isolation of tooth with rubber dam (D3910) provided on March 8, 2021.
You asked the Plan to pay for a surgical procedure for isolation of tooth with rubber dam. You say that you were not told by the provider that the service at issue would not be covered. The Plan denied your request. The Plan says the service at issue 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a surgical procedure for isolation of tooth with rubber dam (D3910) provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two applications of desensitizing resin for cervical and/or root surface provided on March 12, 2021.

You asked the Plan to pay for the applications of desensitizing resin. You say that you were under the impression, and asked a Plan representative, to make sure this service would be covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that several calls were made, and at no time was there question or discussion regarding the application of desensitizing resin.

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 two applications of desensitizing resin for cervical and/or root surface provided on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the resin-based composite provided on March 17, 2021.
You asked the Plan to pay more for the resin-based composite. You say that your dental guide does not reference only a 50% repayment up to the $500 maximum allowance. The Plan denied your request. The Plan says as stated in your EOC and in the Plan's Dental Brochure online, covered dental services under the Optional Supplemental Dental Basic benefit are covered at 50% of the charge up to the maximum allowance of $500.
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, you are responsible for 50% of the billed cost. Therefore, we decided that the Plan does not have to pay more for the resin-based composite provided on March 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on October 26, 2020 by an OON provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that the treating provider depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. The Plan denied your request. The Plan says the services were rendered by an OON provider. The Plan also says that prior 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 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 domiciliary or rest home visit provided on October 26, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wireless capsule endoscopy (91110).

You asked the Plan to pre-approve the wireless capsule endoscopy. You say that you are appealing the denial for the wireless capsule endoscopy. You have had had bleeding internally and both times you have ended up with blood transfusions. The Plan denied your request. The Plan says a repeat wireless capsule endoscopy is not medically appropriate when the AVM (arteriovenous malformation) diagnosis has been established, is duplicative and would not visualize the full upper GI track.

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 wireless capsule endoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has already undergone a capsule endoscopy that has demonstrated arteriovenous malformations in the upper small bowel. A double balloon enteroscopy is planned. The medical records do not provide a sufficient rationale for the medical necessity or reasonableness of the requested service as defined by Medicare rules.

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 wireless capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve the wireless capsule endoscopy (91110).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for a specialist office visit and coinsurance for an injection provided by a participating provider on February 24, 2021.

You asked the Plan to waive the co-payment for a specialist office visit and coinsurance for an injection. You say that these charges are too high. The Plan denied your request. The Plan says the correct charges have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 co-payment for physician/practitioner services/specialist and a 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a $25 co-payment for a specialist office visit and a 20% coinsurance of the allowed amount for an injection. The total allowed amount for the injection is $1,219. The amount you are being asked to pay for an injection is $243.80 ($1,219 x 20% = $243.80). The total amount you are being asked to pay is $2688.80 ($243.80 + $25 = $268.80). A specialist office visit falls within the physician/practitioner services/specialist and an 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 co-payment for a specialist office visit and coinsurance for an injection provided by a participating provider on February 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you had a spinal fusion surgery over 10 years ago. You experienced acute back pain in April of 2021 and developed left hip symptoms. The records do not show any neurologic changes or attempts at conservative treatment. The records do not support that the MRI is reasonable or medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a blepharoplasty (15820).

You asked the Plan to pre-approve the blepharoplasty. You say that the blepharoplasty is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that Medicare does not cover cosmetic surgery or expenses incurred in connection with such surgery.

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 blepharoplasty. Our reviewer says that the blepharoplasty is medically necessary. Our physician reviewer found the record indicates that the enrollee had facial nerve paralysis due to resection of a parotid tumor. The elements of the coverage criteria are satisfied. The requested service is 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 the blepharoplasty have been met. Therefore, we decided that the Plan has to pre-approve a blepharoplasty (15820).

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on February 9, 2021 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the rendering provider did not verify the member's benefits. The Plan says that prior 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 lab work provided on February 9, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the osteogenesis stimulator provided on November 11, 2020 by an out of network provider.

You asked the Plan to pay for the osteogenesis stimulator, low intensity ultrasound, non-invasive (E0760). You say that medical necessity is documented in the records. The Plan denied your request. The Plan says you did not request 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 had network providers available who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the osteogenesis stimulator provided on November 11, 2020 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on February 6, 2020.

You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on February 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Atezolizumab and Bevacizumab - AWWB.
You asked the Plan to pre-approve Atezolizumab and Bevacizumab - AWWB. You say that this request is
medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Atezolizumab and Bevacizumab -
AWWB. Our reviewer says that the requested drugs are not medically reasonable and necessary. Our physician
reviewer found the enrollee has been diagnosed with advanced hepatocellular carcinoma. In this case, the
requested combination of drugs has not been approved by the FDA as 1st line therapy. In addition, the
requested drug combination has not been supported by one of the major drug compendia or by clinical research
that appears in a CMS-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Atezolizumab and Bevacizumab - AWWB have not been met. Therefore, we
decided that the Plan does not have to pre-approve Atezolizumab and Bevacizumab - AWWB.