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

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from June 7, 2017 through June 8, 2017.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 does not support that the criteria for inpatient paymentare met in this case. Our physician reviewer found care provided from June 7, 2017 through June 8, 2017 to the enrollee was observation level. He had stable vital signs and no complaints at the time of admission. He was noted to be ambulatory with a stable gait and was in no acute distress or discomfort. Documentation notes the enrollee was "admitted to observation for placement". There were no advance interventions or complex medical conditions. Inpatient care services were not supported by the documentation for dates of service June 7, 2017 through June 8, 2017.
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 not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from June 7, 2017 through June 8, 2017
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to "the beneficiary" by "the doctor" on June 19, 2019.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.

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 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 medical services provided to "the beneficiary" by "the doctor" on June 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast biopsy provided on February 6, 2019.
You asked the Plan to waive the copayment for a breast biopsy. You say that you disagree with the observation room services. 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 $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received a breast biopsy on February 6, 2019. A breast biopsy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment. You have been asked to pay a $295 copayment for a breast biopsy. A breast biopsy falls within the outpatient surgery and other medical 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 copayment for a breast biopsy provided on February 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for(CPT Code A7032), (CPT Code A4604) and(CPT Code A7034) provided from March 13, 2019 through June 26, 2019.You asked the Plan to pay forthe DME. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DMEhave not been met. Per CMS guidelines codes A7038 and A7032 can only be billed at a maximum of 2 units per month. This limit was met on line items 2 and 5 on claim# 1907020AV7545181. A7035 is allowed at 1 unit every 6 months and per claim history no claims submitted within the last 6 months this line item denied in error. (Claim# 1906280AV7517626) A7034 & A4604 are allowed once every three months. These two codes were paid on claim# 1907020AV7545181 for date of service March 13, 2019.Therefore, we decided that the Plan does not have to pay for(CPT Code A7032), (CPT Code A4604) and (CPT Code A7034) provided from March 13, 2019 through June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on June 26, 2019.You asked the Plan to waive the deductible forthe office visit. You say that youshould not be responsible for the amount. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $150 combined deductible that applies to in-network office visits.The office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 combined deductible that applies towards in-network office visit. The allowed amount for the office visit is $61.03. Therefore, $61.03 is applied to the $150 combined deductible. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on June 26, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe office visit provided on June 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diabetic supplies coded as E0607, A4259, A4259, A4256 and A4258 provided by "the provider". June 6, 2019 to August 25, 2019.You asked the Plan to pay forthe diabetic supplies. You say that you say the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says the records provided do not support the service billed.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid delivery ticket and proof of delivery for the supplies provided in this case. The delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket submitted.Therefore, we decided that the Plan does not have to pay forthe diabetic supplies coded as E0607, A4259, A4259, A4256 and A4258 provided by "the provider". June 6, 2019 to August 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from April 27, 2019 through May 1, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the documentation doesnot support inpatient care is supported after April 26, 2019. There were no ongoing advance interventions or complex medical conditions. Inpatient care from April 27, 2019 through May 1,2019 is not determined medical 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 acute inpatient hospital care have not been met.Therefore, we decided that the 
Plan does not have to pay forthe acute inpatient hospital care provided from April 27, 2019 through May 1, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe spinal injection provided on June 27, 2019.You asked the Plan to waive the copayment forthe spinal injection. You say that you should not be responsible for the copayment because you did not ask for the injection and your provider assured you it would be covered by insurance.The Plan denied your request. The Plan says you have been charged 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 a $100 copayment per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center.You have been asked to pay a $100 copayment for the spinal injection. The spinal injection 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 obligationyou agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe spinal injection provided on June 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dulera.You asked the Plan to pre-approve Dulera. The Plan denied your request. The Plan says drug coverage is limited to Part B covered drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Dulera.Benefits for Dulera may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on October 15, 2019.
You asked the Plan to pay for the dental service. You say that you have been diagnosed with osteoporosis. You say you are scheduled for treatment by infusion of Reclast. You also say that it is recommended a comprehensive dental exam and panoramic x-ray are done before the treatment as the drug could have a detrimental effect on the jaw. The Plan denied your request. The Plan says the frequency limit has been exceeded for the panoramic x-ray.
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 panoramic x-rays are a covered service, the frequency limit of once every 5 years has been exceeded. The record shows you last received a full mouth x-ray on December 27, 2016. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on October 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay from August 22, 2019 to August 29, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that this should not be considered a new inpatient hospital admission and you disagree with the charges.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 ascopayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $372 copayment per day for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from August 22, 2019 to August 29, 2019. This is considered a new inpatient hospital admission. Therefore, you are responsible to pay a $372 copayment for days 1-5 (August 22, 2019 to August 26, 2019). $372 (copayment) x 5 (inpatient days) = $1,860.00. You have been asked to pay the total copayment amount of $1,860.00 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 acontractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran inpatient hospital stay from August 22, 2019 to August 29, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 6, 2018 to June 27, 2019.You asked the Plan to pay for the outpatient mental health services. You say that you were not aware that prior authorization was necessary for these services. The Plan denied your request. The Plan says the services rendered did not meet the criteria for coverage of out of network care without prior authorization.Medicare rules say that plans can requireenrollees 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 December 6, 2018 to June 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the custom fabricated abutment (D6057) for teeth # 3, 5, and 6, the abutment supported retainer (D6068) for teeth # 3, 5, and 6, the pontic(D6245), and the palliative dental care (D9110) provided from August 5, 2019 to August 6, 2019.You asked the Plan to pay the full amount forthe dental services. You say that the Plan covers fixed bridge replacement. You say that you could not get a fixed bridge replacement because your teeth were not in good enough condition. You say that you had to get implants instead.The Plan denied your request. The Plan says custom fabricated abutments are not listed as a covered service. The Plan says that abutment supported retainers are not listed as a covered service. The Plan says palliative dental care is not listed as a covered service. The Plan also says there is a 50% cost share for the pontic, a prosthodontic 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 pontics are a covered service, there is a 50% cost share for the service. Additionally, the custom fabricated abutment, abutment supported retainers, and palliative dental care are not listed as covered services.Therefore, we decided that the Plan does not have to pay the full amount forthe custom fabricated abutment (D6057) for teeth # 3, 5, and 6, the abutment supported retainer (D6068) for teeth # 3, 5, and 6, the pontic (D6245), and the palliative dental care (D9110) provided from August 5, 2019 to August 6, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for an emergency department (ED) visit (99284) provided on May 27, 2019 by Independence Emergency Group LLC.

You asked the Plan to pay for the ED visit. You say that the services should be covered.The Plan denied your request. The Plan says that the billed service is not supported in the medical records.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not provide medical records (for codes 99284 or 99285) or a claim form (showing how code 99285 was billed). Without this documentation, the Plan denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for an emergency department (ED) visit (99284) provided on May 27, 2019 byIndependence Emergency Group LLC.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from July 29, 2019 through August 2, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctorexpects 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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. He had stable vital signs and no complaints at the time of admission.Inpatient care services were not supported by the documentation.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 not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from July 29, 2019 through August 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial intraoral x-ray (D0220), and the crown (D2750) for tooth # 3 provided from September 24, 2018 to November 12, 2018.You asked the Plan to pay forthe initial intraoral x-ray, and crown. The Plan denied your request. The Plan says the frequency limit for a crown or bridge recement has been exceeded. The Plan also says that intraoral x-rays is not listed as 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 crowns are listed as a covered service, the frequency limit of 1crown or bridge recement has been exceeded. The record shows that you received a bridge recement for tooth # 8 that was paid for by the Plan. Additionally, intraoral x-rays are not listed as a covered service.Therefore, we decided that the Plan does not have to pay forthe initial intraoral x-ray (D0220), and the crown (D2750) for tooth # 3 provided from September 24, 2018 to November 12, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora duplex scan (93925) provided on August 16, 2019 by out of network provide.You asked the Plan to pay fora duplex scan. You say that you are appealing claim payment denial for services rendered to the Plan's member on date of service August 16, 2019.The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC. Medicare rules say that plans can require enrollees to get care from network providers. Thecontract 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 fora duplex scan (93925) provided on August 16, 2019 by out of network provider.