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

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from April
24, 2020, through May 5, 2020.
You asked the Plan to pay for inpatient hospital care. You say that you submitted supporting documentation for
reconsideration of adjustment. The Plan denied your request. The Plan says payment of DRG 871 is not
supported. The Plan states review supports DRG 175. The Plan states principal diagnosis code assignment of
A41.9, Sepsis, unspecified organism was reported by the hospital. The Plan states according to coding
guidelines and documentation in the medical record this condition did not qualify for reporting, and the
determination to remove principal diagnosis code A41.9, Sepsis, unspecified organism is upheld.
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 A41.9 - Sepsis. 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 inpatient hospital care. Our physician reviewer found the criteria for such a
diagnosis using updated guidelines does not appear to have been met for this enrollee on this admission. There
was no evidence of a severe infection or organ failure to describe sepsis. Therefore, the principal diagnosis
code assignment of A41.9, Sepsis, is not sufficiently supported in the documentation provided.
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 care provided to the enrollee from April 24, 2020, through May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99212, 99213) provided March 29,
2021 to April 30, 2021.
You asked the Plan to pay for the office visit. You say that you understand an office visit and a manipulation
can not be done on the same day. You were not aware the office would bill this way. The Plan denied your
request. The Plan says the service is not covered when rendered by a chiropractor.
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 service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the outpatient office visit (99212, 99213) provided March 29, 2021 to April
30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on May 25, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an
attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we
decided that the Plan does not have to pay for psychotherapy services (90834) provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network
(OON) provider on August 12, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers in cases involving emergencies, out of
area urgent care and pre-approved care. Additionally, the Plan offers a supplemental travel benefit that provides
coverage for services received in other states with some exclusions. The enrollee may get care from out-of-
network providers in all states except the following: Illinois, Iowa, Michigan, Minnesota, and Wisconsin.
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at
issue. The Plan offers a supplemental travel benefit that provides coverage for services received in other states
with some exclusions. The enrollee may get care from out-of-network providers in all states except the
following: Illinois, Iowa, Michigan, Minnesota, and Wisconsin. The service at issue in this case was provided
in the state of Wisconsin. We found no exception that would require the Plan to pay for this service. Therefore,
we decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network
(OON) provider on August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to pay for medical services provided from February 27, 2019, to March 12, 2019 denied by the Plan under denial code "D" for outside the dates of service.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says due to an audit, the Plan partially recouped and adjusted this claim. The Plan states the services denied with denial code "D" for outside the dates of service were upheld and it is noted the provider agrees with these findings. The Plan notes after further review of the submitted documentation the Plan approved the services initially denied with denial code "B".
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this was an administrative denial due to an audit in which both the Plan and the provider agreed on those services paid, and those services denied. Therefore, we decided that the Plan does not have to pay for medical services provided from February 27, 2019, to March 12, 2019 denied by the Plan under denial code "D" for outside the dates of service
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) provided on July 20, 2021.
You asked the Plan to pay for the dental services. You say that you feel that the oral exam should be covered
since one of the previous exams was provided in conjunction with an extraction. The Plan denied your request.
The Plan says 2 exams are covered per year. The Plan says that the frequency limit 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 and oral exams are covered, the
frequency limit has been exceeded. The record shows that the Plan paid for oral exams that you received on
January 25, 2021, and February 5, 2021.
Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) provided on July 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from May 30, 2021, to
June 1, 2021.
You asked the Plan to pay for the self-administered drugs. You say that these medications were given to you by
the doctor that asked for them. The Plan denied your request. The Plan says self-administered drugs are not
covered by Part B.
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 the self-administered drugs
provided from May 30, 2021, to June 1, 2021.
Benefits for the self-administered drugs 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Bone marrow
aspirate remains experimental for use as bone graft substitute in spinal surgery. More research is needed to
show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for
coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 3,
2021.
You asked the Plan to pay for the dental service. You say that you are barely getting by on Social Security. You
also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says 1 limited oral
evaluation is covered per plan year. The Plan also says that the frequency limit 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 and the service is listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you
received on February 10, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral
evaluation (D0140) provided on March 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for surgical services provided on August 3,
2021, at an out-of-network hospital.
You asked the Plan to waive the coinsurance for out-of-network surgical services. You say that the medically
necessary procedure at issue should not be treated as out-of-network because it could only be performed by the
original surgical group at the recommendation of your cardiac physician. The Plan denied your request. The
Plan says the correct coinsurance was applied.
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 50%
coinsurance for outpatient surgery at an out-of-network outpatient hospital or ambulatory surgical center.
You have been asked to pay $1,279.56, or 50% of the Medicare-allowed total charge of $2,559.13, for out-of-
network surgical services. Surgical services 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 coinsurance for surgical services provided on August 3, 2021, at an out-of-network hospital.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for treatment with Collagenase injection
(J0775) provided on June 15, 2021.
You asked the Plan to waive the coinsurance for Collagenase. You say that you were never notified in advance
by either the Plan or the provider that you would be looking at such a charge for the medication at issue. The
Plan denied your request. The Plan says the correct coinsurance was applied.
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 chemotherapy drugs and all other drugs covered under Medicare Part B.
You have been asked to pay $723.51, or 20% of the Medicare-allowed total charge of $3,617.65, for
Collagenase. Collagenase 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 treatment with Collagenase injection (J0775) provided on June 15,
2021.
Your complaint about not receiving full information about your cost-sharing responsibilities from the Plan or
from your 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for esophagogastroduodenoscopy, flexible, transoral; with
biopsy, single or multiple (43239) provided May 5, 2021.
You asked the Plan to pay for the outpatient services. You say that you are appealing the charges for screening
tests of a colonoscopy and biopsy and an upper GI endoscopy. You are appealing the $696.69 total. The Plan
denied your request. The Plan says the claim was processed correctly and applied to the deductible as the
enrollee had not yet met the deductible.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is $1,000 deductible which applies to Outpatient surgery, including
services provided at hospital outpatient facilities and ambulatory surgical centers.
The item or service you asked the Plan to pay for falls within the benefit category Outpatient surgery, including
services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed
Medicare rules by clearly disclosing in the contract that there is $1,000 deductible. After you pay $1,000
deductible you pay $300 copay for each Medicare covered outpatient surgery at an ambulatory surgical center
which applies to Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers. This cost sharing is a contractual obligation that had not been met at the time the outpatient
services was received on May 5, 2021. Therefore, we decided that the Plan does not have to pay for
esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239) provided May 5,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and additional periapical
x-rays (D0230 x 3) provided on June 25, 2021.
You asked the Plan to pay for the dental services. You say that you assumed that what the dentist was doing
was part of the benefit for your insurance. The Plan denied your request. The Plan says periapical x-rays are not
listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the periapical x-rays are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial
periapical x-ray (D0220) and additional periapical x-rays (D0230 x 3) provided on June 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral evaluation (D0120) and prophylaxis (D1110) provided
on August 5, 2021.
You asked the Plan to pay for the dental services. You say that your dentist has been having issues with getting
your plan to honor your claims. The Plan denied your request. The Plan says the provider in this case is out of
network. The Plan also says that dental services received out of network are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network
are not among those covered under this benefit.
Additionally, the record shows that the Plan advised in a letter dated April 1, 2021, that a one-time exception
was made for services previously received from the provider in this case and that no further services from this
provider would be covered. Therefore, we decided that the Plan does not have to pay for oral evaluation
(D0120) and prophylaxis (D1110) provided on August 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation
program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit
from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth per quadrant (D4341) for the upper right and lower right quadrants, provided August 7, 2021.
You asked the Plan to pay for the periodontal scaling and root planing. You say that your dental services were pre-approved and you do not understand why they are not covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.
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 periodontal scaling and root planing once per quadrant every two plan years. We looked at the file and Medicare rules. The Plan provided documentation showing that periodontal scaling
and root planing were previously covered for the same quadrants (upper right and lower right) on July 24, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the periodontal scaling and root planing has been exceeded. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth per quadrant (D4341) for the upper right and lower right quadrants, provided August 7, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from
September 10, 2020, through September 17, 2020.
You asked the Plan to pay for inpatient hospital care. You say that you submitted supporting documentation for
reconsideration of adjustment. The Plan denied your request. The Plan says payment of DRG 871 is not
supported. The Plan states review supports DRG 602. The Plan states principal diagnosis code assignment of
A41.9, sepsis unspecified organism was reported by the hospital. The Plan states according to coding
guidelines and documentation in the medical record this condition did not qualify for reporting as the principal
diagnosis. The Plan states a clinical review of the appeal letter and the documents submitted did not validate
A41.9 as the principal 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 A41.9 - sepsis unspecified organism. 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 inpatient hospital care. Our physician reviewer found the
diagnosis code, A41.9, sepsis unspecified organism, was not sufficiently supported by the records as there was
no evidence of organ failure due to the infection or a rise in SOFA that would meet criteria, and the enrollee
was overall quite stable.
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 care provided to the enrollee from September 10, 2020, through September 17, 2020.