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

We decided that the Plan has to pay for the outpatient hospital services provided on February 19, 2021.

You asked the Plan to pay for the outpatient hospital services. You say that these services were correctly billed in the outpatient setting. The Plan denied your request. The Plan says that this was billed with an inappropriate diagnosis code.

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. The Plan has not provided a compelling argument to support denial of payment in this case. The claim was originally denied stating that the procedure codes used were inconsistent with the place of service. However, there is no evidence to support that the outpatient place of service was inappropriate. On appeal review, the Plan changed its denial rationale stating that the claim cannot be paid because the diagnosis code is not appropriate. The Plan did not specify the diagnosis code is inappropriate as several are reported on the claim. No citation was provided to support that the diagnosis is not appropriate. As such, we find that the denial is not substantiated. Therefore, we decided that the Plan has to pay for the outpatient hospital services provided on February 19, 2021.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the custodial services provided to the enrollee from November 18, 2020, through November 19, 2020.
You asked the Plan to pay for the custodial services. You say that the services were necessary. The Plan denied your request. The Plan says the SNF admission was initially approved but the request was then cancelled because the enrollee did not stay in the facility very long before transferring back to the hospital and ultimately discharging to another location. The Plan states the enrollee spent approximately six (6) hours in this facility before transferring back to the hospital and the facility cancelled the request and made that stay a custodial day. The Plan states the enrollee received no skilled therapy or skilled nursing during those hours in the facility.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custodial services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the custodial services provided to the enrollee from November 18, 2020, through November 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventative medical evaluation, the influenza vaccine,
and the administration provided on February 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the preventative medical evaluation, the influenza vaccine, and the
administration. You say that the provider was unaware authorization was needed. You say the service was
medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 preventative medical evaluation, the influenza
vaccine, and the administration provided on February 22, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cataract surgeries provided from 
March 22, 2021, to April 5, 2021. 
 
You asked the Plan to waive the copayments for the cataract surgeries. You say that you have already paid the 
copayments. You say you should get a refund. The Plan denied your request. The Plan says you have been 
asked to pay the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for an in-network ambulatory surgical center.

You have been asked to pay a $350 copayment for the cataract surgeries on each date of service. The cataract 
surgeries fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the cataract 
surgeries provided from March 22, 2021, to April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion supplies provided on July 28, 2020, to July 31, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the OON infusion supplies. You say that the code billed is allowable and payable for infusion supplies. You say that the infusion supplies are crucial for the safe administration of IV antibiotic therapy. The Plan denied your request. The Plan says there was no necessity for the use of an OON provider. The Plan says that a non-network provider referred the enrollee to this OON supplier.

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 infusion supplies provided on July 28, 2020, to July 31, 2020, 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 office visit (99214) provided on April 12, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $50 copayment for a specialist office visit rendered by an out-of-network provider. 

You have been asked to pay a $50 copayment for the specialist office visit rendered by an out-of-network provider. 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 office visit (99214) provided on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental scaling (code D4346).

You asked the Plan to pre-approve dental scaling. You say that you were hospitalized, and your teeth are in
poor condition. The Plan denied your request. The Plan says this service is not covered by the Plan's dental
benefits.

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 pre-approve dental scaling (code D4346).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, harness, and electrical 
connection for a power wheelchair. 
 
You asked the Plan to pre-approve power wheelchair components. You say that the enrollee meets the 
Medicare criteria and these components are medically necessary. The Plan denied your request. The Plan says 
the denial of authorization for these components is correct, because the enrollee is able to control the 
wheelchair's power options with their own switches. 
 
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 power wheelchair components. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation that the expandable controller, harness, and 
electrical connection are medically reasonable and necessary. Records indicate that the enrollee has 4/5 
bilateral upper extremity strength and is independent with feeding and toileting. Based on this information, she 
appears to have adequate upper extremity strength and function to control the power options with their own 
switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair components have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an expandable controller, harness, and electrical connection for a power 
wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient admission provided from February 18, 2021, to February 22, 2021.
You asked the Plan to waive the copayment for the inpatient admission. You say that you were told there was a $0 copayment for days 1 to 20 for skilled nursing care. You say this is a large, unexpected amount to pay. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment per day for days 1 to 5 per admission.
You have been asked to pay a $325 copayment, for each day, of the inpatient admission. ($325 x 4 = $1,300). The inpatient admission falls within the "Inpatient hospital care" benefit category. The record shows you were admitted as an inpatient to a rehabilitation hospital. 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 inpatient admission provided from February 18, 2021, to February 22, 2021.
Your complaint about being given misinformation 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 the office visit coded 99213 provided on January 30, 2021.

You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 99213 is office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter. 

We find that CPT code 99213 is not supported in the medical record. Specifically, this code was billed without an appropriate modifier. There is no documentation of significant, separately identifiable evaluation and management. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99213 provided on January 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 2, 2021.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says with limited exceptions, an enrollee may be required to use network providers to get medical care and services. The only exceptions are emergencies, or urgently needed services when the network is not available.
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 physician's services. 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 physician's services provided on March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the complete upper denture (D5110) and the complete lower denture 
(D5120) provided on February 24, 2021. 
 
You asked the Plan to pay for the dental items. You say that when you enrolled in the plan, you were told that 
if you decided to use the services of an out of network provider, you would be charged more and you had to 
pay it. You say that you were never told anything about the services of a doctor who does not participate with 
Medicare. You also say that now you have no teeth and no dentures. The Plan denied your request. The Plan 
says that the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made 
for items and services provided by a dentist that has opted out of Medicare. 
 
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. The Plan covers the dental 
items when the services are medically necessary and reasonable. 
 
We looked at, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental items have been met. The record shows that you were not made aware prior to the 
services being rendered that the provider in this case had opted out of Medicare. The Evidence of Coverage 
clearly states that dentures are covered once every 5 calendar years with a 75% coinsurance when performed 
out of network. Therefore, we decided that the Plan has to pay the out of network rate for the complete upper 
denture (D5110) and the complete lower denture (D5120) provided on February 24, 2021.

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 pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you need LTACH care. The Plan denied your request. The Plan says rules for LTACH have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present setting and is stable for care at a lower level such as skilled nursing facility (SNF). The enrollee does not require services at the LTACH that is not available at a SNF. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 5, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 services provided by an out-of-network provider on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) 
provided July 13, 2020. 
 
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that you would like these 
claims reprocessed and approved for payment. The Plan denied your request. The Plan says the reasonableness 
of the provided durable medical equipment was not established. 
 
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to 
the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our
reviewer says that the equipment in this case provided were not medically reasonable and necessary. Our 
physician reviewer found that the documentation in the case file does not support that the requested knee 
orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the 
coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical 
procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint 
laxity.  
The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 
 
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 knee orthosis and suspension sleeve have not been met. Therefore, we 
decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) 
provided July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 7, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 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 services provided by an out-of-network provider on August 7, 2020.