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

We decided that the Plan does not have to waive the copayment for inpatient mental health services at an out-of-network hospital you received from March 6, 2021, to March 16, 2021.
You asked the Plan to waive the copayment for the inpatient mental health services. You say that you wanted to stay in the hospital an extra day to make sure you didn't have a reaction to medication. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that according to your contract, you only pay a copayment for the first five days of the inpatient stay, so the addition of one more day doesn't change the cost sharing amount due.
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 $360 copayment per day for days 1-5 for inpatient mental health services at an out-of-network facility.
You have been asked to pay a $360 copayment per day for days 1-5 for the inpatient mental health services. 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 inpatient mental health services at an out-of-network hospital you received from March 6, 2021, to March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit and care planning provided by an out-of-network provider on February 8, 2021.
You asked the Plan to pay for the home visit and care planning. You say that the facility requested the physician to see the patient as an attending provider in an outpatient capacity. You say that the medical records prove the need for the services rendered and the claim should be processed for reimbursement. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.
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 home visit and care planning provided by an out-of-network provider on February 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on December 1, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that you had authorization for this. You say that you should not have a copayment 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 $30 copayment for physician/practitioner services/specialist visit. You have been asked to pay a $30 copayment for a specialist office visit. The correct copayment has bene applied to the services that were provided. A specialist office visit falls within the physician/practitioner
services/specialist visit 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
office visit provided by a participating provider on December 1, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your
request. The Plan says that there are no skilled needs at this time.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 care. Our reviewer says that the
requested admission is medically reasonable and necessary. Our physician reviewer found you do have
documented skilled nursing needs, receiving daily wound care. You do have documented skilled therapy needs,
requiring strength and endurance training. Daily skilled services are required to establish a maintenance
program or to prevent deterioration of your condition.
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 care have been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve admission to a
skilled nursing facility (SNF).
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 occlusal adjustment - limited (D9951) received January 30, 2021.
You asked the Plan to pay for the occlusal adjustment. You say that the requested service should be covered by the Plan. The Plan denied your request. The Plan says the requested service is not covered under your supplemental 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 the occlusal adjustment - limited (D9951) received January 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Bevacizumab and Fosaprepitant injections you received on March 12, 2021.
You asked the Plan to waive the coinsurance for the injections. You say that the cost of these medications is too high. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the injections. The injections fall within the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the coinsurance for the Bevacizumab and Fosaprepitant injections you received on March 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy bra (L8000).
You asked the Plan to pre-approve the bra. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically 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 bra. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not indicate that the enrollee has had a mastectomy. No clinical records are submitted. 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 bra have not been met. Therefore, we decided that the Plan does not have to pre-approve a mastectomy bra (L8000).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a capsule endoscopy (91110) provided February 19, 2021.
You asked the Plan to pay for the capsule endoscopy. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Capsule Endoscopy is payable only for those beneficiaries who have undergone upper gastrointestinal endoscopy and colonoscopy, within the same episode of illness, that have failed to reveal a source of bleeding. We looked at the file and Medicare rules. The records provided show no documentation of a prior endoscopy or colonoscopy. Based on this information, we decided that Medicare rules for coverage of the capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pay for a capsule endoscopy (91110) provided February 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on February 10, 2021.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this copayment. You say that you were an inpatient. 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 $395 copayment for outpatient surgery/in-network. You have been asked to pay a $395 copayment for an outpatient surgery. An outpatient surgery falls within the outpatient surgery/in-network 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 an outpatient surgery provided by a participating provider on February 10, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided between 10:00pm and 8:00am at a 24-hour facility, in addition to basic service (99053) provided November 16, 2020.
You asked the Plan to pay for the after-hour services. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says this procedure is not paid separately.
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, we have confirmed that code the after-hour services has a bundled relationship with code 99825 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for services provided between 10:00pm and 8:00am at a 24-hour facility, in addition to basic service (99053) provided November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), oral hygiene instructions (D1330) and unspecified preventative procedure, by report (D1999) provided March 23, 2021.
You asked the Plan to pay for the oral exam, oral hygiene instructions and unspecified preventative procedure. You say that you were not satisfied with a previous oral exam and therefore believe this one should be covered. The Plan denied your request. The Plan says you have met frequency limits for the oral exam and the remaining 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.
We reviewed the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral evaluation was covered on March 10, 2021. Therefore, the oral exam at issue was not yet eligible for coverage at the time of service. Though the Plan offers a dental benefit in excess of Medicare coverage, the remaining 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 comprehensive oral evaluation (D0150), oral hygiene instructions (D1330) and unspecified preventative procedure, by report (D1999) provided March 23, 2021.
Your complaint about being dissatisfied with previous dental services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on February 3, 2021 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were provided in good faith. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 skilled nursing services provided on February 3, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on September 1, 2020.
You asked the Plan to waive the copayment for the eye exam. You say that you have diabetes and it is covered once per year at no cost to you. You say that you were not charged for this service in the past. The Plan denied your request. The Plan says the copayment applied 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 $15 for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye.
You have been asked to pay a $15 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show a medical eye exam was performed. 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 eye exam provided on September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the core build up (D2950) for teeth # 19 and 21 provided on March 22, 2021.
You asked the Plan to pay the full amount for the dental service. You say that The Plan denied your request. The Plan says there is a 50% coinsurance for major restorative dental services, including core build up.
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 core build is a covered service, there is a 50% coinsurance for major restorative dental services. The record shows that the Plan paid 50% of the allowed amount, $266, for each core build up. $266 x 50% = $133. Therefore, we decided that the Plan does not have to pay the full amount for the core build up (D2950) for teeth # 19 and 21 provided on March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on February 4, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you have never had to pay a copayment for labs in the past. The Plan denied your request. The Plan says you were charged this copayment 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 $5 copayment for lab tests. You have been asked to pay a $5 copayment for the lab services. This copayment applies regardless of whether
or nor you have paid a copayment in the past. 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 services you received on February 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided October 27, 2020 to October 28, 2020.
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 99291 is critical care visit of 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the provided documentation does not detail how much time was spent on this service. Based on this information, we decided that Medicare
rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided October 27, 2020 to October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the catheter placement in coronary artery(s) for coronary angiography (93460) moderate sedation services (99152) provided on December 17, 2020.
You asked the Plan to pay for the catheter placement services. You say that records were submitted for review to support the services rendered were medically necessary and should be paid accordingly. The Plan denied your request. The Plan says information requested from the billing/rendering provider was not provided
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
In this case, medical records are needed to support the services 93940 and 99152. The plan had requested the
medical records from the provider without success. Based on this information, we decided that Medicare rules
for coverage of the catheter placement services have not been met. Therefore, we decided that the Plan does not
have to pay for the catheter placement in coronary artery(s) for coronary angiography (93460) moderate
sedation services (99152) provided on December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307, G0483) rendered by the out of network (OON) provider on November 20, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal.
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 the drug testing (80307, G0483) rendered by the out of network (OON) provider on November 20, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services represented by code 99233 provided on November 23, 2020.
You asked the Plan to pay for code 99233. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare guidelines say that ICD-10-CM has a coding convention that requires the underlying condition to be sequenced first, followed by the manifestation. In this case, R65.21 is a manifestation code and cannot be used as the primary or first-listed diagnosis code on the claim. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services represented by code 99233 provided on November 23, 2020.