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

We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) provided to the enrollee on August 11, 2021.
You asked the Plan to pay for the services. You say that the provider notes support the charges and diagnosis codes billed. The Plan denied your request. The Plan says the diagnosis code billed is not valid as a primary diagnosis.
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 99233 is "Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit."
We find that CPT code 99233 is not supported in the medical record. Specifically, diagnosis code R40.2431 is not appropriate as a primary diagnosis code. It must be billed with an associated primary diagnosis that led to the diagnosis of R40.2431. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) provided to the enrollee on August 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kerendia.
You asked the Plan to pre-approve Kerendia. You say that the enrollee continues to have worsening proteinuria. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B 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 Kerendia.
Benefits for Kerendia 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided from October 22, 2021, to October 27, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that you have applied for in-network status and this claim should be paid. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and there was no approved 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 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 nursing facility care provided from October 22, 2021, to October 27, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received from November 29, 2021, 
to December 1, 2021. 
 
You asked the Plan to pay for the drugs. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not paid by Medicare when submitted on outpatient claims. 
 
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 pay for self-administered drugs received 
from November 29, 2021, to December 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for individual psychotherapy (90832) group psychotherapy 
services (90853) provided April 26, 2021 to May 17, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that please reconsider and reprocess the 
claim for reimbursement. The Plan denied your request. The Plan says this provider type is not eligible in the 
Medicare program. Licensed professional counselors are not eligible to participate in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program.  Licensed professional counselors are not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for individual psychotherapy (90832) group psychotherapy 
services (90853) provided April 26, 2021 to May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a subcutaneous heart rhythm monitor for the 
enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no diagnosis of syncope or stroke, or a history of cryptogenic stroke. 
 
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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found while the enrollee has a history of atrial fibrillation, there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke, or any other apparent indication for this request. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of a subcutaneous heart rhythm monitor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wheelchair provided on September 11, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a wheelchair. You say that you had to go to an out-of-network provider to 
receive the equipment because the in-network providers did not return your calls or refused service. The Plan 
denied your request. The Plan says the rendering provider is an out-of-network provider, and a list of in-
network providers was given to the enrollee prior to the purchase of this equipment. 
 
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 a wheelchair provided on September 11, 2021, by 
an out-of-network (OON) provider.  
 
Your complaint about your experience with an in-network provider is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic procedure 
provided on October 8, 2021. 
 
You asked the Plan to waive the copayment for the outpatient diagnostic procedure. You say that the services 
should be covered. 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 $105 
copayment for Outpatient hospital services.  
 
 
 
 
 
 You have been asked to pay a $56.10 copayment for an outpatient diagnostic procedure, which is less than the 
$105 stated in the Plans contract. Outpatient diagnostic procedures fall within the Outpatient hospital services 
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 an outpatient diagnostic 
procedure provided on October 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the closure of the lacrimal punctum
provided on June 16, 2021.
You asked the Plan to waive the copayment for the closure of the lacrimal punctum. You say that the plugs fell
out of your eyes so you did not receive the medical treatment you needed. The Plan denied your request. The
Plan says the claims were processed correctly and you are being charged the correct 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 outpatient surgery, including services provided at hospital outpatient facilities.
You received the closure of the lacrimal punctum on June 16, 2021, at an outpatient hospital facility. The
closure of the lacrimal punctum is considered an outpatient surgical procedure. Therefore, you are responsible
to pay the $325 copayment.
You have been asked to pay a $325 copayment for the closure of the lacrimal punctum. The closure of the
lacrimal punctum falls within the outpatient surgery, including services provided at hospital outpatient facilities
and ambulatory surgical centers 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 closure of the lacrimal punctum provided on June 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 30, 2020 and
billed with CPT codes 82607, 85651, 86141, 80053, 80061, 81000, 82306, 82728, 82746, 82977, 83036,
83540, 83550, 83615, 84100, 84165, 84443, 84550, 85025, 85044, 86038, 86160, 86200, 86235 and 86431.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says CPT code 82607 has been processed and paid.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient
information in the record to determine if Medicare rules for coverage of laboratory services provided on
December 30, 2020, and billed with CPT codes 82607, 85651, 86141, 80053, 80061, 81000, 82306, 82728,
82746, 82977, 83036, 83540, 83550, 83615, 84100, 84165, 84443, 84550, 85025, 85044, 86038, 86160, 86200,
86235 and 86431. have been met. Specifically, the records indicate that all codes on this claim have been
processed and paid by the Plan. The records do not support that these services were rendered more than once.
Therefore, we decided that the Plan does not have to pay for laboratory services provided on December 30,
2020 and billed with CPT codes 82607, 85651, 86141, 80053, 80061, 81000, 82306, 82728, 82746, 82977,
83036, 83540, 83550, 83615, 84100, 84165, 84443, 84550, 85025, 85044, 86038, 86160, 86200, 86235 and
86431.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2200) provided on October 13, 
2021, by an out-of-network provider. 
 
You asked the Plan to pay for the eyeglasses. You say that these services are necessary, and you would like 
reimbursement. The Plan denied your request. The Plan says the provider in this case is not part of the Plan's 
specified vision network. Routine vision care received out-of-network is not covered by your benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are received from a provider in the Plans vision network. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans specified vision 
network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not 
been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2200) 
provided on October 13, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist chiropractor visit to be provided by an outof-
network (OON) provider.
You asked the Plan to pre-approve a specialist chiropractor visit. You say that you would like to see the out-ofnetwork
provider because they provide a special treatment to help with your pain. The Plan denied your
request. The Plan says an in-network provider has already been approved that provides the same services that
Medicare allows.
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 specialist chiropractor visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services provided to the enrollee on March 10, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there is no established relationship with the ordering provider.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of telehealth services provided to the enrollee on March 10, 2021 have been met.
The provider has not sent in any documentation to show that this was a valid service. It is unable to be verified if the enrollee had these services rendered to them, or if there is an established relationship with the provider. Therefore, we decided that the Plan does not have to pay for telehealth services provided to the enrollee on March 10, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on March 21, 2021.
You asked the Plan to pay for the hospital discharge day management. You say that this charge is prior to the enrollee being in hospice and should be covered. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on March 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) and teledentistry (D9996) provided on September 1, 2021.
You asked the Plan to pay for the preventive procedure and teledentistry. You say that the treating provider is listed in the Plan's 2021 provider's book as being in-network. You also say that you would like the billing to be corrected and your account to be cleared. The Plan denied your request. The Plan says these services are not covered under 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 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
preventive procedure (D1999) and teledentistry (D9996) provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hearing exam provided on October 14, 
2021. 
 
You asked the Plan to waive the copayment for the hearing exam. You say that the services should be covered. 
The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services received 
by the enrollee 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $40 copayment for Hearing services.  
 
 
 
 
 
 The enrollee has been asked to pay a $36.66 copayment for a hearing exam, which is less than the $40 stated in 
the Plans contract. Hearing exams fall within the Hearing services benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a hearing exam provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the local anesthesia (D9215 x2), two resin-based composites of two surfaces (D2331 x2) on tooth #'s 25 and 27, and resin-based composite of three surfaces (D2332) on tooth #26, or pay more for the resin-based composites of two surfaces (D2331) on tooth #'s 23 and 24 provided on November 2, 2021, and November 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the local anesthesia, resin-based composites on tooth #'s 25, 26, and 27, and to pay more for the resin-based composites on tooth #'s 23 and 24. You say that you believe the local anesthesia should be covered. You also say that you are requesting an adjustment on the second visit because the provider did not have time to finish rendering these services during the first visit. The Plan denied your request. The Plan says local anesthesia is not a covered expense under your dental plan, and the frequency for resin-based composites has been exceeded. The Plan says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. The Plan also says that you did not contact the Plan prior to the dates of service to verify benefits and provider eligibility.
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, local anesthesia (D9215) is not among those covered under this benefit. The contract says that two restoration procedure codes per calendar year, and you must pay a 55% coinsurance when the service is received OON. The record shows that you received resin-based composites of two surfaces (D2331) on tooth #'s 23 and 24 on November 2, 2021 and your restorations benefit has been exhausted. You are also responsible for the difference between the billed amount and allowed amount for covered dental services that are received OON. Therefore, we decided that the Plan does not have to pay for the local anesthesia (D9215 x2), two resin-based composites of two surfaces (D2331 x2) on tooth #'s 25 and 27, and resin-based composite of three surfaces (D2332) on tooth #26, or pay more for the resin-based composites of two surfaces (D2331) on tooth #'s 23 and 24 provided on November 2, 2021, and November 9, 2021 by an out-of-network (OON) provider.