Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on April 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not emergent or pre-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 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 for an office visit (99214) provided on April 22, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services provided on May 26, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for wound care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 wound care services provided on May 26, 2020 by an out-of-network (OON) provider
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on June 10, 2021.
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on June 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 4 power wheelchair and accessories.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says group 4 power wheelchair have added capabilities that are not needed for use in the home, and are therefore to be denied as not medically necessary.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a group 4 power wheelchair and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from September 29, 2021, to October 1, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the services should be covered as they were performed against your will. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $100 copayment for Inpatient hospital care.
You have been asked to pay a $100 copayment for inpatient hospital services. 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 inpatient hospital services provided from September 29, 2021, to October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and periodontal maintenance (D4910) provided September 20, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the periodic oral exam, intraoral x-rays, and periodontal maintenance. You say that you have been going to this dentist for years and would like the services to be covered as in-network. The Plan denied your request. The Plan says dental services are not covered when provided OON. Additionally, intraoral x-rays and periodontal maintenance are not covered services under your 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. The Plan covers the periodic
oral exam when provided by a participating provider. We looked at the file and Medicare rules. 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 the periodic oral exam. Though the Plan offers dental benefits in excess of Medicare coverage, the intraoral x-rays, and periodontal maintenance are not among those covered services. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and periodontal maintenance (D4910) provided September 20, 2021, by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on September 14, 2021.
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that the provider filed an incorrect billing code. You also say that code D0230 was submitted by the provider, but the correct code should have been D0210. The Plan denied your request. The Plan says you have exhausted your benefit coverage 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, you are limited to 1 additional intraoral x-ray per year. The record shows that you received two additional intraoral periapical x-rays (D0230 x2) on September 14, 2021, one of which was covered by the Plan, and your additional intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on September 14, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for mental health services (90837) provided on September 1, 2021.
You asked the Plan to waive the copayment for the mental health services. You say that the services should be covered as you are uncomfortable going in person due to covid-19. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $30 copayment for Outpatient mental health care.
You have been asked to pay a $30 copayment for telehealth mental health services. There are no Plan guidelines stating that telehealth copayments will always be waived. 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 mental health services (90837) provided on September 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on July 16, 2020, through July 31, 2020 and billed with Patient Driven Payment Model (PDPM) code OEPE1 x 16 days.
You asked the Plan to pay for the SNF services with PDPM code OEPE1 x 16 days. You say that you would like reconsideration because the documentation supports the PDPM code billed. The Plan denied your request. The Plan says the documentation does not support the coding of mechanically altered diet.
The Plan follows Medicare rules. Medicare rules say that all SNF Part A inpatient services are paid under a prospective payment system (PPS). This involves payment based on a Health Insurance Prospective Payment System (HIPPS) rate code. 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 SNF services with PDPM code OEPE1 x 16 days. Our reviewer says that PDPM code OEPE1 x 16 days does not meet criteria for billing or reimbursement consideration. Our physician reviewer found the documentation is insufficient to support a mechanically altered diet for the enrollee during the period July 16, 2020, through July 22, 2020. 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 SNF services with PDPM code OEPE1 x 16 days have not been met. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on July 16, 2020, through July 31, 2020 and billed with Patient Driven Payment Model (PDPM) code OEPE1 x 16 days.
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 these services are medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for IRF care.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for gastrointestinal bleeding. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services provided on February 26, 2021, March 1, 2021, and March 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 the subsequent hospital care services provided on February 26, 2021, March 1, 2021, and March 5, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee does not appear to be medically stable for transfer to inpatient rehabilitation
facility.
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 the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
respiratory failure, congestive heart failure and pleural effusion. Medical problems are stable. There are no
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical
record supports a need for physical and/or occupational therapy, there is no documented need for intensive
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a
reasonable expectation that you 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are in-network providers 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 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-approve physical therapy services to be provided by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection (36465) provided on August 19, 2021.
You asked the Plan to pay for the injection. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an injection (36465) provided on August 19, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) and to pay more for the crown (D2740) provided on August 31, 2021.
You asked the Plan to pay for the core buildup or pay more for the crown. You say that you were told that you have $1,500 per year to use for dental services. You also say you were told that the crown was covered at 50% on two different occasions. The Plan denied your request. The Plan says this claim processed correctly according to the Plan benefits. The Plan also says that during your call with the Plan on April 23, 2021 you were advised that you would be responsible for a 70% coinsurance for crowns and that core buildups are 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, core buildup, including any pins when required (D2950) is not among those covered under this benefit. The contract also clearly states that you are responsible for a 70% coinsurance for each crown received by an in-network provider. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) and to pay more for the crown (D2740) provided on August 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cystourethroscopy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there are participating providers available to perform these services.
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-approve Cystourethroscopy to be provided by an out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity.
You asked the Plan to pre-approve Trulicity. The Plan denied your request. The Plan says the drug is filled by
the pharmacy benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulicity. Benefits for Trulicity may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out-of-network (OON) provider on July 19, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out-of-network (OON) provider on July 19, 2021.