Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a hip arthroplasty procedure (27130), a physical therapy evaluation (97161), and an occupational therapy evaluation (97165) provided on April 21 to April 23, 2021.

You asked the Plan to waive the cost-sharing for a hip arthroplasty procedure, a physical therapy evaluation, and an occupational therapy evaluation. You say that you were not advised by the provider of any outpatient surgery or care during your stay. The Plan denied your request. The Plan says the correct cost-sharing was 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 20% coinsurance for each visit for outpatient surgery and a $40 copayment for each Medicare-covered therapy visit.

You have been asked to pay $2,635.77, or 20% of the Medicare-allowed charge of $13,178.86, for a hip arthroplasty procedure. A hip arthroplasty procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. You have also been asked to pay a $22.86 copayment for a physical therapy evaluation and a $22.17 copayment for an occupational therapy evaluation. A physical therapy evaluation and an occupational therapy evaluation fall within the "Outpatient rehabilitation services" benefit category. This means that you have been asked to pay less than or equal to 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 cost-sharing for a hip arthroplasty procedure (27130), a physical therapy evaluation (97161), and an occupational therapy evaluation (97165) provided on April 21 to April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140)
provided on May 24, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this dental work was
required by the surgeon. You also say that this service should be reimbursable because the heart surgery is a
covered service. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
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. The only types of exams covered under your plan are routine oral
exams and comprehensive oral exams. Therefore, we decided that the Plan does not have to pay for the
problem focused limited oral evaluation (D0140) provided on May 24, 2021.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency room services provided on January 3, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee presented to the emergency room 
two times on the same day. The Plan denied your request. The Plan says that the documentation supplied did 
not support adjustments. 
 
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. 
 
We looked at the file and the rules. The case file does not contain 2 claims or 2 explanations of benefits to 
show that duplicate claim lines were billed. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request.  Therefore, we decided that the Plan 
has to pay for the emergency room services provided on January 3, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection for a power wheelchair.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee's strength and function in the right upper extremity with the ability to feed himself indicates that he can control any power options through the individual switches. The requested electronic connection is therefore not reasonable or medically
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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection for a power wheelchair
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is ready for transfer. The Plan denied your request. The Plan says an IRF admission 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: SNF
Decision: Favorable

We decided that the Plan has to pay for the Skilled Nursing Facility (SNF) provided on January 1, 2020, 
through April 29, 2020. 
 
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation provided does not 
support the coding of the Section GG activity, Oral Hygiene, as coded on the 5-day Minimum Data Set (MDS) 
assessment which results in a reduction of the Physical Therapy/Occupational Therapy component of the 
Patient Driven Payment Model (PDPM) score. 
 
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's argument is not supported as they have not provided 
sufficient evidence to suggest that the oral hygiene functional assessment as documented by the nurse who 
completed the Minimum Data Set (MDS) form is invalid. The Plan's rationale is based solely on the fact that 
the enrollee's oral hygiene function was not documented in the occupational therapy evaluation and plan of 
care. However, oral hygiene function is not a specific occupational therapy item and was not among the 
activities of daily living that was being treated as part of the plan of care. Therefore, we decided that the Plan 
has to pay for the Skilled Nursing Facility (SNF) provided on January 1, 2020, through April 29, 2020.  
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71046) provided on March 31, 2021.
You asked the Plan to pay for an x-ray. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered as a preprocedural examination.
The Plan must follow Medicare rules. Medicare rules say that in general, preprocedural chest X-rays in the absence of pulmonary or cardiac diseases, chest X-rays in the absence of signs or symptoms, and chest X-rays for minor trauma of the head, lower back or extremities are not the current accepted medical practice. Diagnosis code Z01.818, encounter for other preprocedural examination, does not support medical necessity for chest x-rays.
We looked at the file and Medicare rules. The records show that the x-ray at issue was a preprocedural examination, and the only billed diagnosis on the claim is Z01.818, which does not support medical necessity. Based on this information, we decided that Medicare rules for coverage of an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71046) provided on March 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve octreotide.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has upper gastrointestinal bleeding. The records do not clarify that the bleeding is from an upper source and not from another possible source, such as colonic polyps or diverticulosis. The use of octreotide for this enrollee is not supported in the Medicare-approved major drug compendia. There is no documentation to support that octretide is safe and effective and medically necessary for this enrollee.

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 pre-approve octreotide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the resin based composite (D2335) for 
tooth # 8 provided on June 7, 2021. 
 
You asked the Plan to pay an additional amount for the dental service. You say that per the Benefit Highlight 
flyer, there is a $1,500 limit on all covered services per plan year. You also say that the service should be 
covered. The Plan denied your request. The Plan says there is a $1,500 annual maximum benefit for covered 
dental services. The Plan also says that the annual maximum benefit was exhausted prior to processing the 
claim for this 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 annual maximum benefit has been 
exhausted. The record shows that the Plan paid $409 for dental services received on April 26, 2021, $624 for 
dental services received on May 13, 2021, and $467 for dental services received on the date of service in this 
case. $409+$624+$467=$1,500. Therefore, we decided that the Plan does not have to pay an additional amount 
for the resin based composite (D2335) for tooth # 8 provided on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on June 16, 2021.

You asked the Plan to pay for an eye refraction. You say that you want the Plan to pay for this service. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

Eye refraction is only covered by the Plan when it is performed as part of a routine screening by a participating provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Specifically, eye refraction is only covered by the Plan when it is performed as part of a routine screening by a participating provider. This service was performed for medical vision purposes, and therefore is not a covered benefit. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on June 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on December 24, 2020. 
 
You asked the Plan to pay for the transportation service. You say that you were advised that the ambulance 
company used the incorrect code. You say that it was never corrected. You also say that since it was the middle 
of the coronavirus pandemic, and the bleeding had stopped, you were not transported to the hospital. The Plan 
denied your request. The Plan says the ambulance benefit is a transportation benefit. The Plan also says that 
when there is no transport provided Medicare nor the Plan pay for the services provided.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 24, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on December 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames and progressive lenses provided by an out-of-
network provider on March 31, 2021. 
 
You asked the Plan to pay for the frames and progressive lenses. You say that you are requesting 
reimbursement for what they would have paid to an in-network provider. You say that you have been a client 
since 2013 and are requesting your appeal be reconsidered. The Plan denied your request. The Plan says this 
provider is not a participating provider with the Plan and the claim processed correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are received from a network provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the frames and progressive lenses have not been met. Specifically, the frames and lenses were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the 
frames and progressive lenses provided by an out-of-network provider on March 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided May 11, 2021 to May 17, 2021.
You asked the Plan to waive the copayment for the inpatient services. You say that your first operation was on March 10, 2021. The procedure was not done correctly and you were bleeding for 10 weeks. Your surgeon said you needed immediate surgery. The second operation was no fault of yours. The Plan denied your request. The Plan says this claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $275 copayment each day for days 1 to 5. You have been asked to pay $1375.00 ($275 x 5 days) for the inpatient services. The inpatient services 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 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 inpatient hospital services provided May 11, 2021 to May 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (95908) provided on March 4, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled code. 

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 95908 
has a bundled relationship with code 95868 and cannot be paid as billed. This code cannot be paid as a separate 
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for the services (95908) provided on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D5225 and D5226) provided on July 7, 2021 and July 15, 2021.
You asked the Plan to pay for the dental services (D5225 and D5226). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental codes D5225 and D5226 are covered under the Plan's supplemental dental benefit once every five years; however, these services also fall under the dental annual allowable of $1000. Your current plan states that you have maxed the dental benefit allowed limit of $1000. After the maxed benefit allowed is exhausted, any remaining charges are your responsibility.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file, the Plan's contract and Medicare rules. The Plan contract shows that dental codes D5225 and D5226 are covered under the Plan's supplemental dental benefit once every five years; however, these services also fall under the dental annual allowable of $1000. Your current plan states that you have maxed the dental benefit allowed limit of $1000. After the maxed benefit allowed is exhausted, any remaining charges are your responsibility. The file shows that the Plan paid your $1000 allowed limit for dental services on your January 19, 2021 date of service ($640.16) and on your April 29, 2021 date of service ($359.84). You have maxed out the allowable dental benefit for the year. Therefore, we decided that the Plan does not have to pay for the dental services (D5225 and D5226) provided on July 7, 2021 and July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 18, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have 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 must 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 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 physician services provided to the enrollee on
May 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric lightweight folding wheelchair for the 
enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there has not been an evaluation by a wheelchair provider to see which device is 
appropriate. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the 
documentation does not reveal a detailed evaluation or neuromuscular exam that reveals that the enrollee has a 
personal mobility deficit that impairs participation in MRADLs. There is no documentation that this deficit is 
unable to be overcome by a cane, walker, or manual wheelchair. The documentation does not support that this 
requested wheelchair will significantly improve the enrollee's ability to participate in MRADLs in the home. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electric lightweight folding wheelchair for the enrollee.