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

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 26, 2021 by an OON provider.

You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that your dentist bill was $150.00, and insurance only paid an in-network benefit of $73.00. You also say that your dentist sent you a bill for $77.00, which you would like to be reimbursed for. The Plan denied your request. The Plan says these charges exceed the allowable amounts for these procedures.

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, you are responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 26, 2021 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on January 25, 2021.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing for suspected or documented cardiovascular disease.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The testing at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the multivitamins provided on April 2, 2021.

You asked the Plan to pay for the multivitamins. You say that everything you sent was on the over-the-counter list. The Plan denied your request. The Plan says a doctor's recommendation is needed.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. However, the Plan offers a supplemental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the rules. The file shows that the plan requires a prescription or a note you're your doctor in order to process the claim. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the multivitamins provided on April 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan (78815) provided November 23, 2020
You asked the Plan to pay for the PET scan. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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. We find that CPT code 78815 is not supported in the medical record. Specifically, the claim did not include a valid diagnosis code for the PET scan performed. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan (78815) provided November 23, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and surgical extraction (D7210) provided on March 3, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the problem focused limited oral evaluation and surgical extraction. You say that your dentist referred you to this new oral surgeon to extract your tooth. The Plan denied your request. The Plan says the treating provider has opted out of Medicare. The Plan also says that if you use a provider that has opted out of Medicare, you will not receive reimbursement.
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 covered when they are received by a Medicare opt out provider. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and surgical extraction (D7210) provided on March 3, 2021 by a Medicare opt out provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) and the laboratory service (85610) rendered by the out-of-network (OON) provider on April 9, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 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 hospital outpatient clinic visit (G0463) and the laboratory service (85610) rendered by the out-of-network (OON) provider on April 9, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study services coded 95938 provided on February 2, 2021.
You asked the Plan to pay for the short-latency somatosensory evoked potential study services. 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 95938 is short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs.
We find that CPT code 95938 is not supported in the medical record. Specifically, this service was billed with diagnosis code I65.29 (Occlusion and stenosis of unspecified carotid artery). This diagnosis code is inconsistent with the procedure billed. Based on this information, we decided that Medicare rules for coverage of the short-latency somatosensory evoked potential study services have not been met. Therefore, we decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study services coded 95938 provided on February 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the records received show that the enrollee's condition has improved and is no longer a threat to yourself or others.
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 pre-approve inpatient psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee. It is not expected this enrollee would improve in a reasonable period of time as she does not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. This patient does not show any abnormal behaviors or any symptoms which would require acute treatment. It does 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 beyond as she does not have dangerousness to self or others but was compliant with her treatment. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
January 25, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that your primary care
physician (PCP) told you to go to the hospital because she thought you may have had a stroke. You say you
were not informed there would be a copayment. 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 an $85
copayment for each Medicare-covered emergency room visit (not waived if admitted).
You have been asked to pay an $85 copayment for the emergency room visit. The emergency room visit falls within the "Emergency 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 emergency room visit provided on January 25, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the PET scan, the stress test, the medical supply, and the Part B drugs provided on January 5, 2021.
You asked the Plan to waive the cost share for the PET scan, the stress test, the medical supply, and the Part B drugs. You say that the provider did not inform you of your copayment amounts prior to the test and did not collect the amount on the day of the test. 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 $175 copayment for advanced imaging service (e.g., MRI, CT, PET scans, and stress tests), 20% coinsurance for surgical or medical supplies, and 20% coinsurance for other Medicare-covered Part B drugs. You have been asked to pay a total of $232.34 for the PET scan, the stress test, the Part B drug. The PET scan, the stress test, and the medical supply fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Part B drug fall within the "Medicare Part B prescription drugs" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Copayment/
Coinsurance
Member Liability
January 5, 2021
PET scan
$1,538.81
$175
$175
January 5, 2021
Stress test
$73.92
$175
$14.78 - You have been charged less than the standard amount.
January 5, 2021
Medical supply
$198.80
20%
$39.76
January 5, 2021
Part B drug
$2.00
20%
$0.40
January 5, 2021
Part B drug
$12.00
20%
$2.40
Total
$232.34
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 cost share for the PET scan, a stress test, a medical supply, and Part B drugs provided on January 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services provided on February 2, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services are not Medicare covered.
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the documentation in the beneficiary's medical documentation.
We looked at the file and the rules. We find that transcutaneous electrical never stimulation, vasopneumatic device therapy, and a Nutria-pharmaceutical injection are not supported in the medical record. Specifically, the records provided do not show that these services were provided on the date of service at issue. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the pain management services provided on February 2, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on March 17, 2021.
You asked the Plan to pay for the services provided. You say that the documentation supports the services. The Plan denied your request. The Plan says there are no medical records to determine the clinical utility of the testing.
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the documentation in the beneficiary's medical documentation.
We looked at the file and the rules. We find that the testing at issue is not supported in the medical record. Specifically, the medical records provided do not include a physician order. The records do not clearly document the physician's intent that the test be performed. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing provided on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350) and comprehensive oral evaluation (D0150) provided on May 6, 2021.
You asked the Plan to pay for the 2D oral/facial photographic image and comprehensive oral evaluation. You say that you now understand that your dental insurance only covers one comprehensive oral evaluation every three years, but you are wondering how you can change dentists within that three-year period. You also say that prior to this treating provider you were seen by an unsatisfactory dentist which is why you changed dentists. The Plan denied your request. The Plan says the 2D oral/facial photographic image is not a covered benefit under your dental plan. The Plan also says that the comprehensive oral evaluation exceeds the frequency limitation in your benefit plan.
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 2D oral/facial photographic image (D0350) is not among those covered under this benefit. The contract says that comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on January 15, 2020 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350) and comprehensive oral evaluation (D0150) provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on February 23, 2021.
You asked the Plan to pay for the hearing aids. You say that you were not informed you were required to purchase hearing aids from the specific provider. The Plan denied your request. The Plan says if you choose to schedule an appointment directly with a provider, your service will not be covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid 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. The records show that you did not receive hearing aids from the Plan's specific required provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on February 23, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 21, 2019 to December 26, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the treating physician spent considerable time within the record outlining their opinion on providing inpatient care. You also say that the facts support this independent physician determination given the grave condition of the enrollee, mandating admission. The Plan denied your request. The Plan says that the inpatient level of care was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was admitted for further evaluation and treatment, imaging obtained to rule out normal pressure hydrocephalus, computed tomography of the head once it became available with significant for chronic periventricular white matter ischemic changes no evidence of acute intercranial hemorrhage infarct mass or other acute changes. Electrolytes were replaced, physical therapy (PT) evaluated enrollee and recommended skilled short-term PT, the case manager was consulted to help facilitate placement at a skilled nursing facility (SNF) for continued PT. Our reviewer found that initially there was some difficulty with placement due to bed availability, but the enrollee was ultimately discharged to a SNF on December 26, 2019 for further PT. Our physician reviewer also found that the review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from December 21, 2019 to December 26, 2019.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87541, 87581, 87634, 87640, and 87798 provided on December 12, 2020.
You asked the Plan to pay for the laboratory services. 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.
We find that CPT codes 87486, 87496, 87498, 87541, 87581, 87634, 87640, and 87798 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87541, 87581, 87634, 87640, and 87798 provided on December 12, 2020