Persius/hicric huggingface dataset:
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 without these services you will not be able to regain full mobility of your everyday movement. 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to tolerate 15 hours per week of rehabilitative services or to require regular physician evaluation. Your care needs can be met at a lower level of care such as skilled nursing facility.  

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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient surgical services provided on November 16, 2020, and December 7, 2020.  

You asked the Plan to waive the copayment for the outpatient surgical services. You say that the services should be covered, and you should be refunded. 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 $175 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.   

You have been asked to pay a $175 copayment for outpatient surgical 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 outpatient surgical services provided on December 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for contrast injections and evaluations of an existing drain currently placed in the soft tissues of the coccygeal bed for an abscess/seroma (49424) rendered from August 26, 2021, to September 7, 2021.  

You asked the Plan to waive the copayment for contrast injections and evaluations of an existing drain currently placed in the soft tissues of the coccygeal bed for an abscess/seroma. You say that there has been no surgery, no incision anesthesia, and no invasive procedures, just contrast through tubes. You also say that you are living on a retired teacher's retirement and $300 is a lot for each treatment. The Plan denied your request. The Plan says you were charged the correct copayment 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 $300 copayment for each visit for surgical procedures, including but not limited to cardiac catheterizations, angiogram, endoscopy, epidural injections, and non-screening colonoscopies in an outpatient hospital facility.   

You have been asked to pay a $300 copayment for contrast injections and evaluations of an existing drain currently placed in the soft tissues of the coccygeal bed for an abscess/seroma on August 26, 2021, and on September 7, 2021, which is a total of $600 ($300 copayment x 2 visits = $600). Contrast injections and evaluations of an existing drain currently placed in the soft tissues of the coccygeal bed for an abscess/seroma fall 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 contrast injections and evaluations of an existing drain currently placed in the soft tissues of the coccygeal bed for an abscess/seroma (49424) rendered from August 26, 2021, to September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for surgery services provided on October 15, 2021.  

You asked the Plan to waive the copayment for surgery services. You say that you needed the services because it was a side effect from the coronavirus (COVID-19). The Plan denied your request. The Plan says the proper copayment was applied for the services received.  

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 $400 copayment for Surgery Services in an Outpatient Hospital.     

You have been asked to pay a $400 copayment for surgery services. Surgery services falls 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 surgery services provided on October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for ophthalmological services, medical examination (92012) and fundus photography with interpretation and report (92250) provided on September 14, 2021.  You asked the Plan to pay for ophthalmological services, medical examination (92012) and fundus photography with interpretation and report (92250). The Plan denied your request. The Plan says the claim was sent with a medical diagnosis and this provider only has routine vision affiliations with the Plan.  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 Plan must follow Medicare rules. Medicare rules say Fundus Photography is not covered for routine screening.  We looked at the file, the Plan's rules and the Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. Medicare says that Fundus Photography is not covered for routine screening. 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 ophthalmological services, medical examination (92012) and fundus photography with interpretation and report (92250) provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit provided on September 1, 2021.  You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as it was just a wellness visit. 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 $20 copayment for Physician/Practitioner services, including doctor's office visits.     You have been asked to pay a $20 copayment for an office visit. The claim includes a diagnosis of Hyperlipidemia, which is what caused it to be billed as an office visit instead of a wellness visit. The Plan is not assessing a copayment for the influenza vaccine. 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 office visit provided on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the oral exam (D0120), bitewing x-rays (D0274), and periodontal maintenance (D4910) provided on September 29, 2021, by an out-of-network dentist.  

You asked the Plan to pay an additional amount for the dental services. You say that the charges should be paid. The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service. The Plan says that dental services received out of network are paid based on the in-network fee schedule. The Plan also says that out of network dentists may bill you for any amount greater than what the Plan pays. 

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 periodontal maintenance is not among those covered under this benefit. The record shows that the Plan paid 50% of the allowed amount for the oral exam and bitewing x-rays. Additionally, out of network dentists may bill you for any amount greater than what the Plan pays. Therefore, we decided that the Plan does not have to pay an additional amount for the oral exam (D0120), bitewing x-rays (D0274), and periodontal maintenance (D4910) provided on September 29, 2021, by an out-of-network dentist.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve whole body bone scan (78306).  You asked the Plan to pre-approve whole body bone scan. You say that the enrollee has confirmed metastatic rectal adenocarcinoma, stage 4, and you are requesting this for restaging purposes. The Plan denied your request. The Plan says the clinical documentation submitted does not support medical necessity.  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 whole body bone scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the record indicates that the enrollee has stage IV adenocarcinoma of the rectum with metastases to the liver and lung. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of whole body bone scan have not been met. Therefore, we decided that the Plan does not have to pre-approve whole body bone scan (78306).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for ophthalmological services provided on December 4, 2020.  

You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.  

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 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 ophthalmological services provided on December 4, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound guidance for vascular access (76937) provided on June 5, 2021.  

You asked the Plan to pay for the ultrasound guidance for vascular access. You say that you would like this claim reprocessed based on the medical documentation provided. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code edit.  

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 76937 is a column II code to column I code 93971. 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 the ultrasound guidance for vascular access (76937) provided on June 5, 2021.
Appeal type: ER
Decision: Partially Favorable

 We decided that the Plan has to pay for the critical care services. We decided that the Plan does not have to pay for electrocardiogram services.   You asked the Plan to pay for the critical care services. You say that these services were billed correctly. The Plan says that the documentation does not support payment for the services as billed.  We decided that the Plan has to pay for the critical care services.   The Plan follows Medicare rules. Medicare rules say that critical care is a time-based service, and for each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided.  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 critical care services. Our reviewer says that the documentation supports the critical care services as billed. Our physician reviewer found the medical records support that the services were performed for 35 minutes which is between the required 30-74 minutes. The records clearly demonstrate these services were performed. The Plan's claim that these services were already paid to another provider is not supported as there is no evidence presented of an additional claim for the critical care services.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the critical care services have been met. Therefore, we decided that the Plan has to pay for the critical care services.   We also decided that the Plan does not have to pay for electrocardiogram services.  The Plan follows Medicare rules. Medicare rules say that a diagnosis of I21.3, defined as ST elevation (STEMI) myocardial infarction of unspecified site, is not a diagnosis code that supports medical necessity.  We looked at the file and Medicare rules. In this case, the diagnosis billed for these services was I21.3 which is not an acceptable diagnosis for coverage based on Medicare rules. Based on this information, we decided that Medicare rules for coverage of electrocardiogram services have not been met. Therefore, we decided that the Plan does not have to pay for electrocardiogram services.  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 pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).  

You asked the Plan to pre-approve a complete upper and lower denture. You say that the dentures you received in 2019 do not fit. You have returned to the dental provider over 20 times to have the dentures fixed. You also say you would like to obtain a new set of dentures with a new provider. The Plan denied your request. The Plan says your current dentures are less than 60 months old, therefore, replacement dentures 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. The Plan covers a complete upper and lower denture every 60 months.     

We looked at the file and Medicare rules. The records show that you received a complete upper and lower denture on April 16, 2019, therefore, you have exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of a complete upper and lower denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility. 

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Shingrix (Zoster) vaccine provided on June 29, 2021.  You asked the Plan to pay for the vaccine services. You say that it was necessary for you to receive this immunization at your provider's office. The Plan denied your request. The Plan says this vaccine is not among those covered under the Plan's medical benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the vaccine services. Therefore, we decided that the Plan does not have to pay for the Shingrix (Zoster) vaccine provided on June 29, 2021.   Benefits for the vaccine services 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for guided tissue regeneration - resorbable barrier, per site (D4266), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, including elevation of mucoperiosteal flap if indicated (D7210), bone replacement graft for ridge preservation - per site (D7953), and bitewings - two radiographic images (D0272) provided November 9, 2020, by an OON provider. You asked the Plan to pay for the guided tissue regeneration, tooth extraction, bone replacement graft and bitewing x-rays. You say that this was the only provider available to provide the services.  The Plan denied your request. The Plan says these services are not covered when provided out-of-network (OON). Additionally, the Plan states that you were made aware in a customer service phone call on November 5, 2020, that your plan did not have OON 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 guided tissue regeneration, tooth extraction, bone replacement graft and bitewing x-rays when the services are medically necessary and performed by a network dentist.  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 these items/services. Based on this information, we decided that the Plan's rules for coverage of the guided tissue regeneration, tooth extraction, bone replacement graft and bitewing x-rays have not been met. Therefore, we decided that the Plan does not have to pay for guided tissue regeneration - resorbable barrier, per site (D4266), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, including elevation of mucoperiosteal flap if indicated (D7210), bone replacement graft for ridge preservation - per site (D7953), and bitewings - two radiographic images (D0272) provided November 9, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the retainer crown (D6750) and pontic (D6240) provided on September 8, 2021.  You asked the Plan to pay an additional amount for the dental services. You say that you received pre-approval for these services. You say that you would not have gone through with the procedure if it had not been approved. You also say that the services should be covered. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,500 for covered dental services. The Plan also says that the maximum benefit has been exceeded.    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 annual maximum benefit has been exceeded. The record shows that the Plan paid $42 for services received on February 2, 2021, $115 for services received on April 7, 2021, and $1,343 for services received on September 8, 2021. $42 + $115 + $1,343 = $1,500. Additionally, the Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for the retainer crown (D6750) and pontic (D6240) provided on September 8, 2021.