Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost share amount forthe oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on July 29, 2020.You asked the Plan to pay the full cost share amount forthe dental services. You say that the booklet shows only 50% member responsibility. You also say that the claim did not process that way.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says that dental services rendered out of network may be subject to a higher cost share amount. The Plan also says that out of network providers may bill for any amount greater than the payment made by the plan to the provider.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, dental services that you receive out of network are subject to a higher cost share. The Evidence of Coverage clearly states that out of network providers may bill for any amount greater than the payment made by the plan to the provider.Therefore, we decided that the Plan does not have to pay the full cost share amount forthe oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for cone beam CT image capture with limited field of view - less
than one whole jaw (D0380) provided on July 30, 2020.
You asked the Plan to pay for cone beam CT image capture with limited field of view - less than one whole
jaw. You say that you would like the cone beam CT image covered as it was the only option to get an image
through your bridge. The Plan denied your request. The Plan says this service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The service must be listed in
your EOC to be covered.
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. Specifically, the service was not listed in Plan's 2020 EOC as a
covered benefit. Therefore, we decided that the Plan does not have to pay for cone beam CT image capture
with limited field of view - less than one whole jaw (D0380) provided on July 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on August 12, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe lab services. You did not provide an argument for coverage in your appeal request.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. The Plan says that neither the provider of service nor the referring provider is a Plan provider.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.You are not a network provider with the Plan. The Plan did not pre-approve the service 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 forthe lab services provided on August 12, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric services provided.

You asked the Plan to pay for these services. You say that the inpatient psychiatric services provided were medically necessary.The Plan denied your request. The Plan says that the inpatient psychiatric services provided were not prior authorized and were not medically necessary. 

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 these services. Our reviewer says that the inpatient psychiatric services provided were not medically necessary. Our physician reviewer found that the enrollee was admitted to acute inpatient psychiatric hospitalization. Based upon the review of the records provided, it was not expected that this enrollee would improve in a reasonable period of time as she did not have dangerousness to self or others and was not showing any auditory/visual hallucinations or any aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she did not have dangerousness to self or others. 
It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or were for the purpose of a diagnosis. An individualized treatment plan was not provided in the record. Based upon the review of the records provided,the admission of this patient does not meet criteria for coverage of acute inpatient mental health treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric services provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pay forhospital discharge day management services (CPT 99239) provided to the enrollee on March 9, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysCurrent Procedural Terminology (CPT) code 99239 (1 Unit) remains not supported.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 99239 is "hospital discharge day management; more than 30 minutes."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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found a documented duration of time of 31 minutes or more is required to support this code. Therefore, the billed service cannot be verified. The review has determined that the records do not support that CPT 99239 was performed for a documented duration of 31 minutes or more.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 services have not been met.Therefore, we decided that the Plandoes not haveto pay forhospital discharge day management services (CPT 99239) provided to the enrollee on March 9, 2020
Appeal type: Testing
Decision: Favorable

We decided that the Planhasto pay foresophagogastroduodenoscopy services (CPT 43239 and CPT 43245) provided to the enrollee on May 28, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthatthis claim does not meet the MUE requirements.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report serviceswith the appropriate CPT code. In this case, the CPT Code Manual definition of the denied codes is:CPT 43239:Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple.,CPT 43245:Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum, as appropriate; with dilation of gastric outlet for obstruction (e.g., balloon, guidewire, bougie)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 services. Our reviewersays that the services at issue in this case were supported by the medical records. Our physician reviewer found the documentation in the case file supports that the coding of CPT 43239 and CPT 43245 were reported correctly in this case.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 services have been met.Therefore, we decided that the Planhas to pay foresophagogastroduodenoscopy services (CPT 43239 and CPT 43245) provided to the enrollee on May 28, 2020.If the Plandoes 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 toreview. The Plan has to show us the mistake and/orsend 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 medical services provided on July 7, 2020 to July 14,
2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that authorization should not be needed under
telemedicine. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 file shows that the enrollee was seen for a routine follow up visit. The 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. 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 on
July 7, 2020 to July 14, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe thoracic lumbar sacral orthosis (TLSO) rendered on July 3, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary.We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe thoracic lumbar sacral orthosis (TLSO) rendered on July 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for post cataract eyeglasses provided on July 16, 2020.You asked the Plan to pay for the post cataract eyeglasses. The Plan denied your request. The Plan saysthat the Plan does notpay more than the allowed amount for eyeglasses.The Plan contract saysthat says that the Plan pays a 20% coinsurance for one pair of standard Medicare-covered eyeglasses or contact lenses. Progressive lenses, no-line bifocal or trifocal lenses, tinting (except for certain ultraviolet-screening coatings), scratch-resistant coatings, or oversizelenses are not covered unless required by Medicare coverage guidelines.We looked at the file and the Plan's rules. The file shows that the Plan paid the correct allowed amount for the eyeglasses.Therefore, we decided that the Plan does not have to pay for post cataract eyeglasses providedon July 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you are deteriorating due to lack of rehab at the current facility. The Plan denied your request. The Plan says you are able to perform activities of daily living, and walk an extensive amount with assistive devices.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 physician reviewer found that you were admitted to the acute hospital for sepsis in November 2020, then discharged to skilled nursing where you have been receiving therapy services. Your medical conditions are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe observation services received from July 9, 2020 to July 10, 2020.You asked the Plan to waive the copayment forthe observation services. You say that this cost share liability would create a financial hardship for you.The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.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 outpatient hospitalobservation. You have been asked to pay a $400 copayment for the observation services. The observation services fallwithin the outpatient hospital observation benefit category. This means that you have been asked to pay the correct amount based on yourcontract 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 forthe observation services received from July 9, 2020 to July 10, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlab services provided on October 2, 2020.You asked the Plan to waive the copayment forlab services. You say that the test is related to a previous visit and should be included in that copayment.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 $5 copayment for lab services. You have been asked to pay a $5 copayment for lab services. Lab services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 forlab services provided on October 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating ambulatory center on July 22, 2020.You asked the Planto waive the copayment for a diagnostic colonoscopy. You say that this was supposed to be routine. You say that polyps were not removed. 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 $450 copayment for outpatient surgery/in-network/ambulatory surgical center. You have been asked to pay a $450 copayment for a diagnostic colonoscopy. The colonoscopy that was provided was diagnostic in nature; therefore, the correct copayment has been applied. A diagnostic colonoscopy fallswithin the outpatient surgery/in-network/ambulatory surgical center 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 diagnostic colonoscopy provided by a participating ambulatory center on July 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveproton beam radiation therapy (PBRT).You asked the Plan to pre-approvethe PBRT. You say that the requested treatment is medically necessary.The Plan denied your request. The Plan says there is no current research that shows the requested type of treatment would improve the enrollee's outcome.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 PBRT. Our reviewer says that PBRT is not considered medically reasonable and necessary in this case. Our physician reviewer foundthat, while proton therapy is not an experimental therapy, any potential benefit for detriment of proton therapy over standard intensity modulated radiation therapy (IMRT) is an investigational question. Other treatment approaches, like IMRT and image guided radiation therapy (IGRT), are also highly effective and well tolerated. Our physician reviewer found that, whether proton therapy affords a benefit over other standard approaches for prostate cancer is an area of investigation and remains controversial. There are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients.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 PBRT have not been met.Therefore, we decided that the Plan does not have to pre-approveproton beam radiation therapy (PBRT)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe colonoscopy and biopsy (45380) to be provided by an out-of-network (OON) provider.You asked the Plan to pre-approvethe colonoscopy and biopsy. You say that the Plan's in-network facilities are too far away.The Plan denied your request. The Plan says they have multiple in-network facilities available for the enrollee to receive their medical treatment.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe colonoscopy and biopsy (45380) to be provided by an out-of-network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee on May 19, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says claims must be processed by Medicare in order to considered filed/submitted.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until June 10, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for radiology services provided to the enrollee on May 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on February 25, 2020,by an out-of-network (OON) provider.You asked the Plan to pay forthe lab services. You say that these services were reasonable and necessary.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 service 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 forthe lab services provided on February 25, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary/mandibular denture.

You asked the Plan to pre-approve the dentures. You say that this is medically necessary.The Plan denied your request. The Plan says this service is covered under the benefit package, but exceeds the maximum count allowed per period.

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 dentures once every five years.

Dentures were last received less than five years ago. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met.Therefore, we decided that the Plan does not have to pre-approve a complete maxillary/mandibular denture.