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

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a necessity for you. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested care is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that you do not require the intensity of services provided at an IRF. Specifically, you have not been shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive service (D1999), and the protective restoration (D2940) provided on December 10, 2020.
You asked the Plan to pay for the unspecified preventive service and protective restoration. You say that your dentist advised that these services are not cosmetic in nature. You say that these services were necessary to avoid more expensive treatment later. You also say that you feel these services should be covered. The Plan denied your request. The Plan says The Plan says that unspecified preventive service is not listed as a covered service. The Plan also says that protective restoration 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, the unspecified preventive service and protective restoration are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified preventive service (D1999), and the protective restoration (D2940) provided on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual wellness visit (G0439) provided December 30, 2020.
You asked the Plan to pay for the annual wellness visit. You say that the services are a covered benefit. The Plan denied your request. The Plan says an annual wellness visit was already paid in the same Calendar year.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for an annual wellness visit (G0439) provided December 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for chest x-ray (71046) complete ultrasound examination of the abdomen (76700) provided on March 8, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the diagnostic services. You say that you are asking for an appeal. You were on time and you were on the organization enrollment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 chest x-ray (71046) complete ultrasound examination of the abdomen (76700) provided on March 8, 2021 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from May 22, 2020, to May 27, 2020.
You asked the Plan to pay for the self-administered drugs. You say that the enrollee required assistance with their medication. You say that the enrollee had already paid for, and had an ample supply of, the medications that were administered in the hospital. You also say that they would not allow the enrollee could not use the medications he had already paid for. The Plan denied your request. The Plan says the drugs that the enrollee received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare
Part D prescription drug plan. The Plan also says the drugs the enrollee received are not covered under Medicare Part B.
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 pay for the self-administered drugs provided in an outpatient setting from May 22, 2020, to May 27, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the 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 reimburse the member liability for the bitewing x-rays (D0274) provided on December 21, 2020.
You asked the Plan to reimburse the member liability for the dental service. You say that you understand that your plan does not cover all of the charges. You say that the bitewing x-rays should be covered. You also say that you should be reimbursed for this charge directly as you have already paid the provider. The Plan denied your request. The Plan says bitewing x-rays are listed as a covered service. The Plan also says there is a $40 copayment for dental visits performed out of network.
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 bitewing x-rays are a covered service, dental visits performed out of network have a $40 copayment. The record shows that the $40 copayment was applied to the bitewing x-rays ($29) and the periodic oral evaluation ($11). $29 + $11 = $40. Therefore, we decided that the Plan does not have to reimburse the member liability for the bitewing x-rays (D0274) provided on December 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need the IRF level of care. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested care is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that you do not require the intensity of services provided at an IRF. Specifically, you have not been shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation.
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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the skilled nursing facility (SNF) services provided from November 1, 2020, to November 17, 2020.
You asked the Plan to waive the cost sharing for the SNF services. You say that had the SNF been coronavirus-free, your mother could have been discharged before the cost sharing kicked in. The Plan denied your request. The Plan says the cost sharing was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day for days 1-20, and a $178 copayment per day for days 21-100 for SNF care. Records show that the enrollee was admitted to the SNF on October 18, 2020 and was discharged on November
17, 2020, for a total of 30 days. The enrollee was not charged a copayment for the first 10 days in accordance with the Evidence of Coverage. The enrollee was then charged a copayment of $178 per day for the next six days, because they had met their annual out-of-pocket maximum. So, the remaining 4 days did not have a copayment assessed. This cost sharing applies regardless of the reason for the length of the stay. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the skilled nursing facility (SNF) services provided from November 1, 2020, to November 17, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87631) provided November 6, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the test performed was not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. We looked at the file and Medicare rules. The testing performed included 6 or more pathogens. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87631) provided November 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested care is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee has not been shown to require fifteen hours per week of rehabilitative services and
regular physician evaluation. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on February 9, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on March 1, 2021.
You asked the Plan to pay for the dental service. You say that you were experiencing tooth pain. You say that you went to the dentist and they performed x-rays. You say that you were sent to an endodontist. You also say that the endodontist said they had to take their own x-rays. The Plan denied your request. The Plan says 1 set of bitewing x-rays are covered per plan year. The Plan also says that the frequency limit has been exceeded.
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 bitewing x-rays are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the bitewing x-rays
that you received on January 29, 2021. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on March 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (81404, 81479) provided October 13, 2020.
You asked the Plan to pre-approve the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all Cardiovascular Risk Assessment panels, except the basic lipid panel. We looked at the file and Medicare rules. The service at issue is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81404, 81479) provided October 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
January 26, 2021, through January 27, 2021.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says based upon the medical the documentation, the care delivered is consistent with an observation stay.
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 that the enrollee is a 67-year-old female with recurrent small bowel obstructions and recent abdominal pain who was admitted to the hospital with a new partial small bowel obstruction based on the computerized tomography findings. The enrollee reported vomiting and worsening severe pain. A nasogastric (NG) tube was placed. The enrollee reported bowel movement that morning but not passing gas. Plans included nonoperative care including NG tube, pain control, nausea control, and fluids with serial abdominal x-rays. There were no factors documented in the records to suggest this enrollee would require hospital services that would likely cross 2 midnights as she was stable and required mostly conservative care.
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 for the acute inpatient hospital care provided from January 26, 2021, through
January 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient bladder surgery you had at an outpatient hospital facility on December 15, 2020.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you were never told you would owe anything beyond a specialist copayment. 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 $400 copayment for surgery or services in an outpatient hospital facility. You have been asked to pay a $400 copayment for the outpatient surgery. 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 outpatient bladder surgery you had at an outpatient hospital facility on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received March 29, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like the Plan to cover this service. The Plan denied your request. The Plan says the requested service is only covered once every three years.
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 service is only covered under this benefit once every three years. The Plan last covered this procedure for you on November 10, 2020. When you received this service on March 29, 2021 the benefit was exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received March 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on April 22, 2021.
You asked the Plan to waive the copayment for the breast ultrasound. You say that this service should be covered in full. 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 $45 copayment for ultrasounds. You have been asked to pay a $45 copayment for the breast ultrasound. There is no provision in your contract for a waiver of this copayment, even if this ultrasound is performed along with your mammogram. 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 breast ultrasound you had on April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival flap procedure (D4241) and the bone replacement graft, first site, (D4263) provided on February 22, 2021.
You asked the Plan to pay for the dental services. You say that you feel these services should be covered. The Plan denied your request. The Plan says gingival flap procedure is not listed as a covered service. The Plan also says that bone replacement graft is not listed as a covered service either.
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 gingival flap procedure (D4241) and the bone replacement graft, first site, (D4263) provided on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (C9752, 22899).
You asked the Plan to pre-approve the Intracept procedure. You say that the services are medically necessary. The Plan denied your request. The Plan says the procedure is considered investigational and is non-covered.
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 Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the radiofrequency ablation of the intraosseous basivertebral nerve is experimental at this time and is not the standard of care. 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (C9752, 22899).