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

 
We decided that the Plan does not have to pay for dental services (D0120, D0220, D0230, D0274, D1110) 
provided June 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were never notified that your dental 
benefits had been dropped. The Plan denied your request. The Plan says the enrollee was notified of changes to 
the dental benefit via mail. The enrollee had no coverage at the time the services were rendered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services (D0120, D0220, 
D0230, D0274, D1110) provided June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs
provided on May 19, 2021.
You asked the Plan to waive the coinsurance for Part B drugs. You say that you paid the maximum out-ofpocket
amount in April 2021, so the Plan should pay this amount. The Plan denied your request. The Plan says
the coinsurance amount you are being charged is correct.
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 in-network Part B drugs, up to a maximum out-of-pocket amount of $7,550. At the time this
claim was processed, $7,074.63 of the $7,550 maximum out-of-pocket amount had been met. The allowed
amount of these drugs total $3,847.02, resulting in a coinsurance amount of $475.37 because this amount met
the $7,550 maximum out-of-pocket amount for 2021.
You have been asked to pay 20% coinsurance for Part B drugs. Part B drugs falls within the Medicare Part B
Prescription Drugs 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 coinsurance for Medicare Part B
prescription drugs provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint ablation (64635, 64636).

You asked the Plan to pre-approve the facet joint ablation procedure. You say that the interventions are
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered when medically
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 the facet joint ablation procedure. Our
reviewer says that the requested facet joint interventions are not medically necessary. Our physician reviewer
found the enrollee has non-localized pain and multiple sites are being requested. Non-facet pathology has not
been ruled out.

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 facet joint ablation procedure have not been met. Therefore, we decided that
the Plan does not have to pre-approve facet joint ablation (64635, 64636).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery services provided
from July 23, 2020, through July 29, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service 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 $475
copayment per stay for outpatient hospital surgery.

You have been asked to pay a $475 copayment for the outpatient hospital surgery provided. 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 outpatient surgery services provided from July 23, 2020, through
July 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that you were approved for a shoulder
arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The Plan says there
is no documentation provided to support the expectation you will require a greater than 2 midnight stay.

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 does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found you are approved for a shoulder arthroplasty. The record does not document that the
treating physician has a reasonable expectation of a length of stay spanning 2 or more 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 not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the beneficiary is an 87-year-old female with
recent cerebrovascular accident, encephalopathy, hypertension and urinary tract infection. While there are
identifiable skilled therapy service needs, the beneficiary does not require skilled nursing or therapy services
daily. In addition, the beneficiary does not require skilled nursing or therapy services daily. In conclusion, this
beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled
nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the discission of a secondary membranous
cataract; laser surgery (66821) provided on May 13, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service 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 $250 copayment per day for other outpatient
procedures and services, including, but not limited to, diagnostic and therapeutic endoscopy, and outpatient
surgery performed in an outpatient hospital or ambulatory surgical center.
You have been asked to pay a $250 copayment for the outpatient surgery performed in an outpatient hospital.
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 discission of a secondary membranous cataract; laser
surgery (66821) provided on May 13, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to further pay for the x-ray services (72100), office visit (99203), and
chiropractic manipulative treatment (98941) provided from March 15, 2021, to March 22, 2021.
You asked the Plan to further pay for the medical services. You say that you would like to be reimbursed for
these medical services. The Plan denied your request. The Plan says these claims have processed correctly.
X-ray services and office visit
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the x-ray services and office visits are not manual manipulation of the spine. These
services are not covered in this case as they are not manual manipulation of the spine.
Chiropractic manipulative treatment
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 $20
copayment for chiropractic services.
You have been asked to pay a $20 copayment for manipulative chiropractic treatment. These services fall
within the Medicare-covered chiropractic 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 further pay for the x-ray services (72100), office visit
(99203), and chiropractic manipulative treatment (98941) provided from March 15, 2021, to March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on September 15, 2020.

You asked the Plan to waive the copayment for the specialist office visit. You say that the service was covered. 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 $20 copayment for provider and professional services provided at an in-network specialist's office. 

You have been asked to pay a $20 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 specialist office visit provided on September 15, 2020.
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 are in danger of not returning to a functional life.
The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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. While the documentation
supports a need for physical and/or occupational therapy, there is no documented need for an intensive,
multidisciplinary 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for patient of extreme age (99100) provided on March 4, 2021.

You asked the Plan to pay for the anesthesia for patient of extreme age. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says payment for this claim is always bundled into payment for other services not specified and no separate payment is made.

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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) .

We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT code 99100. Based on this information, we decided that Medicare rules for coverage of the anesthesia for patient of extreme age have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia for patient of extreme age (99100) provided on March 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Tecentriq, Mvasi, ondansetron hydrochloride
(HCL), lorazepam, promethazine hydrochloride (HCL), and diphenhydramine hydrochloride (HCL).
You asked the Plan to pre-approve Tecentriq, Mvasi, ondansetron HCL, lorazepam, promethazine HCL, and
diphenhydramine HCL. You say that you are appealing with supporting records. The Plan denied your request.
The Plan says the denial of authorization for this drug combination is correct, because this combination is not a
medically accepted regimen as a second line treatment for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Tecentriq, Mvasi, ondansetron HCL,
lorazepam, promethazine HCL, and diphenhydramine HCL. Our reviewer says that the enrollee does not meet
the Medicare criteria for the requested combination of drugs. Our physician reviewer found the requested use
of Tecentriq, Mvasi, ondansetron HCL, lorazepam, promethazine HCL, and diphenhydramine HCL is not Food
& Drug Administration (FDA) approved for the enrollee's diagnosis. This combination is indicated for first line
treatment, but this enrollee has received prior systemic treatment with nivolumab. This combination is not
supported by one of the major drug compendia or by clinical research appealing in a Medicare-approved
medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Tecentriq, Mvasi, ondansetron HCL, lorazepam, promethazine HCL, and
diphenhydramine HCL have not been met. Therefore, we decided that the Plan does not have to pre-approve
use of Tecentriq, Mvasi, ondansetron hydrochloride (HCL), lorazepam, promethazine hydrochloride (HCL),
and diphenhydramine hydrochloride (HCL).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 17, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services provided on June 17, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request.
The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you are an 89-year-old male with prostate
cancer and cerebrovascular accident with right sided weakness. There are no identifiable skilled nursing service
needs and there are no identifiable skilled therapy service needs. In addition, you do not require skilled nursing
or therapy services daily. In conclusion, you do not meet severity of illness or intensity of service criteria for an
inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that your doctor thinks it is necessary for you to go to
the SNF. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled
nursing facility (SNF) setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on June 16, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you were told there would be no cost for the CT scan. You say you were told this was a regular follow-up and the provider said they would bill at no cost. 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 $325 copayment for other Medicare-covered diagnostic radiology services that are not ultrasounds. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $325 copayment for the CT scan.
You have been asked to pay a $126.45 copayment for the CT scan. The CT scan falls within the other "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the CT scan provided on June 16, 2021.