Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve the requested device. You say that you cannot prick your fingers due to neuropathy of your fingers. The Plan denied your request. The Plan says the device for monitoring is not reasonable and medically necessary.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.   We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiographic images (D0274), prophylaxis (D1110), and periodic oral exam (D0120), provided on January 27, 2021.  You asked the Plan to pay for the radiographic images, prophylaxis, and periodic oral exam. You say that you did not know you did not have dental coverage. The Plan denied your request. The Plan says you do not have any dental coverage.  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 the radiographic images (D0274), prophylaxis (D1110), and periodic oral exam (D0120), provided on January 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD), flexible, transoral (43235).  You asked the Plan to pre-approve an EGD. You say that this is medically necessary. The Plan denied your request. The Plan says the requested service is not medically necessary.  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 an EGD. Our reviewer says that the requested EGD is not medically necessary. Our physician reviewer found the provided documentation does not support a recent change in the enrollee's symptoms, red flag criteria, loss of therapeutic response to proton-pump inhibitors (PPI) therapy, nor physical findings to warrant a EGD. The reviewer also found that the provided documentation does not show any enumeration of risk factors for the enrollee were provided to warrant EGD screening for Barrett's esophagus, for pre-operative assessment, nor for endoscopic intervention of dysphagia. Therefore, the reviewer found that the requested EGD is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an EGD have not been met. Specifically, the file does not indicate a change in the enrollee's symptoms that would warrant a repeat esophagogastroduodenoscopy (EGD). Therefore, we decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD), flexible, transoral (43235).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 13, 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 was no documented result of a prior biopsy.  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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, there was no documented result of prior prostate biopsy. There was no documented significant interval increase in prostate-specific antigen (PSA) level. The review has determined that the enrollee was not indicated for this testing.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81345) provided June 29, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.  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 81345 shares a bundled relationship with code 0089U which was also billed. 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 lab services (81345) provided June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating provider on June 21, 2021.  You asked the Plan to pay for a limited oral evaluation. You say that you were in a lot of pain. You say that you were sent from your dentist to a specialist and had an oral exam there as well. The Plan denied your request. The Plan says the benefit limit for D0140 has already been exhausted.  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 limited oral evaluation when the services once every calendar year.   We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating provider on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the crown (D2740) provided on July 6, 2021, by an
OON provider.

You asked the Plan to pay more for the crown. You say that you were advised that the provider was in-network.
The Plan denied your request. The Plan says this service was 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 when the provider contacted the Plan for benefits,
they were advised that they are OON.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, you are 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 more for the crown (D2740) provided on July 6, 2021, by an
OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided from March 17, 2020, to March 20, 2020, and billed with secondary diagnosis code J96.21.    You asked the Plan to pay for the inpatient hospital services billed with secondary diagnosis code J96.21. You say that the secondary diagnosis code billed is supported by the documentation in the medical record and evidence-based medical literature. The Plan denied your request. The Plan says a clinical review of the appeal letter and documents submitted did not validate J96.21 as a secondary diagnosis code for this admission.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with secondary diagnosis code, J96.21, defined as acute and chronic respiratory failure with hypoxia. 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 inpatient hospital services billed with secondary diagnosis code J96.21. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation supported an admission for chronic obstructive pulmonary disease (COPD) with acute exacerbation. The documentation was inconsistent regarding a diagnosis of acute and chronic respiratory failure. Even though respiratory failure was documented in the physician query and discharge summary, supporting medical record documentation was not found within the record. The enrollee was a then, 58-year-old female with a past medical history of history of smoking and COPD with no home oxygen use. She presented to the emergency department with worsening shortness of breath and dyspnea. A chest x-ray showed "no acute abnormality." The enrollee was treated with supplemental oxygen, bronchodilators, IV Solumedrol and IVF. Treatment was consistent with acute respiratory failure including administration of oxygen 5L or more or bi-level positive airway pressure (BiPAP) and/or mechanical ventilation was not within the record. Although the provider documented acute and chronic respiratory failure with hypoxia, reasonable support within the health record must be present for that diagnosis. The review has determined that a clinical review of the appeal letter and documents submitted did not validate J96.21 as a secondary diagnosis code for this admission.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided from March 17, 2020, to March 20, 2020, and billed with secondary diagnosis code J96.21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4) and drugs or medicaments dispensed in the office for home use (D9630) or pay more for the four periodontal scalings and root planings (D4341 x4) provided on August 3, 2021, and August 6, 2021 by out-of-network (OON) providers.  You asked the Plan to pay for the gingival irrigations and drugs or medicaments and to pay more for the scalings and planings. You say that you do not feel it is fair that you are being charged for these services. The Plan denied your request.  The Plan says the gingival irrigations and drugs or medicaments are not covered under your plan. The Plan also says that the scalings and planings were paid at reasonable and customary rate for the OON providers.  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, gingival irrigation (D4921) and drugs or medicaments dispensed in the office for home use (D9630) are not among those covered under this benefit. 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 four gingival irrigations (D4921 x4) and drugs or medicaments dispensed in the office for home use (D9630) or pay more for the four periodontal scalings and root planings (D4341 x4) provided on August 3, 2021, and August 6, 2021 by out-of-network (OON) providers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953)
provided on August 2, 2021.
You asked the Plan to pay for the bone replacement graft. You say that this service should be reimbursed under
your insurance policy. The Plan denied your request. The Plan says this service is not a covered benefit under
your dental 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 bone replacement graft for ridge preservation
(D7953) provided on August 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the two x-rays of the wrist you had on March 4, 2021.  You asked the Plan to waive the copayments for the x-rays. You say that only x-rays of the hands were ordered. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that it has confirmed that the $15 copayment you made was credited to your account, leaving you a balance of $45 for the remaining 3 x-rays.  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 $15 copayment each for x-rays.   Records show that you received a total of 4 x-rays on this date of service: the right hand, the right wrist, the left hand, and the left wrist.  You are not disputing the copayments for the hand x-rays. You have been asked to pay a $15 copayment each for the x-rays. The Plan confirmed with the ordering doctor that he did indeed order x-rays of the wrist in addition to the ones of the hands.  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 copayments for the two x-rays of the wrist you had on March 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from April 5, 2021, to April 7, 2021.  You asked the Plan to waive the copayment for inpatient hospital care. You say that the charges were paid and then reprocessed. 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 $350 copayment, per stay, for inpatient hospital care.   You have been asked to pay a $350 copayment for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital care 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 inpatient hospital care provided from April 5, 2021, to April 7, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to reduce the copayment for office visit. We also decided that the Plan does not have to fully waive the copayment for the office visit.  You asked the Plan to waive the copayment for the office visit. You say that you went to this appointment at your doctor's request for follow ups for your cataract surgery.   The Plan says that you have been charged the correct cost sharing amount.  The Plan follows Medicare rules. 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 enrollees must pay a $30 copayment for each visit to diagnose and treat diseases and conditions of the eye.  The file shows that the office visit was a follow up regarding your cataract surgery. The Plan says you must pay a $40 copayment for the office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $30 copayment for the office visit. The office visit falls in the Vision Care benefit category. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan has to reduce the copayment for the office visit, but does not have to fully waive the copayment, for the cataract surgery follow up visit provided on April 21, 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 office visit (99213) provided on February 17, 2021, by an
OON provider.

You asked the Plan to pay for the out-of-network care. You say that you were not told this provider was out-of-network
and they did not check your insurance card. You say your doctor referred you to this provider. The
Plan denied your request. The Plan says no referral from your primary care provider was submitted for review.
The services at issue were not urgent or emergent. Out-of-network care is only covered in certain limited
circumstances, which have not been met in this case.

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. You say that you were referred to this provider by another doctor, but no documentation
of this referral was submitted with your appeal. We found no exception that would require the Plan to pay for
these items/services. Therefore, we decided that the Plan does not have to pay for the office visit (99213)
provided on February 17, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital services (99232) provided May 2, 2021.  You asked the Plan to pay for the hospital services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code 99232 is not supported in the medical record. Specifically, the place of service was billed as inpatient (21) however the record shows the enrollee was an outpatient at the time. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to pay for hospital services (99232) provided May 2, 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
March 22, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you spent little time with
the doctor and were only informed of your patient status. The Plan denied your request. The Plan says you have
been charged 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 $35
copayment for services obtained in a specialist's office.
You have been asked to pay a $35 copayment for the specialist office visit. The record shows you received
services while you were at the office. 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 March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services provided from March 1, 2020, to March 14, 2020.  You asked the Plan to waive the copayment for the SNF services. You say that you only just received the bill and have only been given two weeks to pay it.  You stated that no one will call you back and you don't understand why this is being billed more than a year later. The Plan denied your request. The Plan says the enrollee was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment for days 1-20, and a $160 copayment per day for days 21-60 for skilled nursing facility services.   Records show that the enrollee was in the SNF from February 11, 2020, to March 14, 2020, for a total of 32 days.  The enrollee was not charged a copayment for the first 20 days.  For the remaining 12 days, the enrollee was charged a $160 copayment per day, for a total of $1920.  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. This cost sharing applies regardless of when the facility sends you the bill. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services provided from March 1, 2020, to March 14, 2020.