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

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from July 6, 2021, to July 10, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you thought your copayment was only $100 per visit, not $100 per day. You stated that this is an emotional and financial hardship for you. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 per day for days 1-7 for inpatient hospital care. Records show that you were in the hospital for 5 days. You were charged a $100 copayment per day, for a total of $500. This is clearly laid out in your Evidence of Coverage. 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 you received from July 6, 2021, to July 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided by a participating provider on May 27, 2021.

You asked the Plan to pay for a comprehensive periodontal evaluation. You say that you were told that all the dental services that were provided were covered services. The Plan denied your request. The Plan says the dental services that were provided are 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided by a participating provider on May 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70480) provided on July 5, 2021.
You asked the Plan to pay for a CT scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable without a modifier.
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 70480 is a column II code to column I code 70450. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (70480) provided on July 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the device implantation procedure you had at an ambulatory surgery center on December 18, 2020.
You asked the Plan to waive the copayment for the device implantation procedure. You say that you had met your out-of-pocket maximum for the year. The Plan denied your request. The Plan says you had not yet met your annual out-of-pocket maximum until after this claim processed. The Plan has adjusted the amount due for this service to $295.
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 $295 copayment for surgery and other services at an ambulatory surgery center.
You have been asked to pay a $295 copayment for the device implantation procedure. The device implantation procedure falls within the surgery and other services at an ambulatory surgery center benefit category. The Plan has confirmed that you had not met your annual out-of-pocket maximum at the time of these 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 the device implantation procedure you had at an ambulatory surgery center on December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740), provided on August 16, 2021.
You asked the Plan to pay for the crown. You say that the service should be covered. The Plan denied your request. The Plan says you have met your maximum allowance for supplemental dental services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown (D2740), provided on August 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies (K0553), provided on April 17, 2021.
You asked the Plan to pay for the diabetic supplies. You say that the items should be covered. The Plan denied your request. The Plan says Medicare guidelines have not been met for proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery. The date of service does not match the date of delivery and there is no shipping documentation. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the diabetic supplies (K0553), provided on April 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear interpretation rendered on April 26, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. We looked at the file and Medicare rules. Billed procedure code 85060 (blood smear interpretation) has a PC/TC indicator of 8. The file shows that the services were not performed for a hospital inpatient. Therefore, we decided that the Plan does not have to pay for the blood smear interpretation rendered on April 26, 2021
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the surgical services rendered on March 11, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that procedure code 30901 is not supported.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that procedure code 30901 is not supported because there is no documentation of a physical therapy evaluation of high complexity; however, procedure code 30901 does not represent a physical therapy evaluation. The definition of this code is control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method. The Plan has not provided any documentation to support that this code is not payable as billed. Therefore, we decided that the Plan has to pay for the surgical services rendered on March 11, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and intraoral complete series (D0210), provided on April 29, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and intraoral complete series. You say that the services should be covered. The Plan denied your request. The Plan says your dental benefits have been exhausted for these services.
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. Specifically, the records indicate you have exhausted your Plan's benefit for these services. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and intraoral complete series (D0210), provided on April 29, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3320) provided on November 3, 2020.
You asked the Plan to pay for the root canal. You say that this service was necessary, and you believed the enrollee had endodontic benefits. The Plan denied your request. The Plan says this service is not covered by your dental benefit. In addition, the Plan reviewed the call log information and found that the specific service at issue was not mentioned during the call.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the root canal (D3320) provided on November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2392), provided on February 1, 2021.

You asked the Plan to pay for the resin-based composite. You say that the services should be covered. The Plan denied your request. The Plan says you obtained theses services from a provider who has opted out of Medicare.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2392), provided on February 1, 2021.
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 you would like an IRF admission covered. The Plan denied your request. The Plan says you do not meet the criteria for IRF admission
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 your 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 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 acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray
(D0220), core build up (D2950), root canal (D3310), and crown (D2740), provided on from April 25, 2021, to
May 9, 2021.

You asked the Plan to pay for the dental services. You say that you woke up with severe tooth pain. You say
that there was only 1 facility that was open for emergency services on a Saturday. The Plan denied your
request. The Plan says the provider in this case is out of network. The Plan also says that dental services
received out of network 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, dental services received out of network
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for
the limited oral evaluation (D0140), periapical x-ray (D0220), core build up (D2950), root canal (D3310), and
crown (D2740), provided on from April 25, 2021, to May 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray
(D0220) provided on June 4, 2021.

You asked the Plan to pay for the dental services. You say that the way the dentist office coded the claim
resulted in you getting a bill. You also say that you did not expect to have to pay for these services. The Plan
denied your request. The Plan says the limited oral evaluation is not listed as a covered service. The Plan says
that the periapical x-ray is not listed as a covered service either.

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 limited oral evaluation and
periapical x-ray are not among those covered under this benefit. Therefore, we decided that the Plan does not
have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion pre-heart/kidney transplant evaluation to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network second opinion visit. You say that the services should be covered. The Plan denied your request. The Plan says there are network providers available to provide the 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 a second opinion pre-heart/kidney transplant evaluation to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI)
joint.
You asked the Plan to pre-approve SI joint RFA. You say that your pain level is between a 7 and 8 and relief
did not last long. The Plan denied your request. The Plan says the denial of authorization for this service is
correct, because this procedure is considered experimental/investigational.
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 SI joint RFA. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found according to medical literature, sacral lateral nerve branch blocks and/or ablations/neurotomies
for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and
investigational. Radiofrequency ablation for denervation, when performed using traditional, cooled, or pulsed
radiofrequency, is considered experimental and investigational.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SI joint RFA have not been met. Therefore, we decided that the Plan does not
have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for outpatient hospital clinic visit you had on
April 27, 2021.
You asked the Plan to waive the cost sharing for the outpatient hospital clinic visit. You say that you shouldn't
have to pay this high of a bill to see a doctor. You have been with the plan since last year and never before
received a facility charge. The Plan denied your request. The Plan says you were charged this copayment
correctly. The Plan says that the allowed amount of $143.97 applied to your deductible correctly.
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 $395
copayment for non-surgical visits in an outpatient clinic after you meet your $395 deductible.
You have been asked to pay the allowed amount of $143.97 towards your deductible outpatient hospital clinic
visit. Your Evidence of Coverage advises you that when you visit a provider, you may be charged an additional
fee. This fee reflects a trend in hospitals buying doctors' practices and addition additional fees to patient bills.
In those cases, the outpatient cost-sharing applies to the services. You should ask every provider's office you
visit if you will be charged an additional fee and if there is another office where you can see the provider
without paying the fee. That was the case here. This doctor works out of an outpatient hospital clinic. 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 sharing for outpatient hospital clinic visit you had on April 27, 2021
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (90837) rendered by an out-of-network (OON) provider on April 9, 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 a primary care physician referral or 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, pre-approved care, and via the POS benefit option with a PCP referral. 

You are not a network provider with the Plan. The Plan did not receive a primary care physician referral and did not issue prior authorization for this service. 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 psychotherapy (90837) rendered by an out-of-network (OON) provider on April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87481, 87798, 88305, 88312) rendered by the out-of-network (OON) provider on June 19, 2020.
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 laboratory services (87481, 87798, 88305, 88312) rendered by the out-of-network (OON) provider on June 19, 2020.