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

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 10, 2021.  You asked the Plan to pay for the comprehensive oral evaluation. You say that the problems you have incurred were because of misunderstandings and the Plan's extremely limited approved sources. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded. The Plan also says that when you contacted the Plan on August 18, 2021 you asked about exams and were advised that comprehensive oral evaluations are allowed once every three calendar years, and since you have already had one performed you would not be eligible for another.  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, comprehensive oral evaluation (D0150) is limited to one procedure code every three years. The record shows that you received a comprehensive oral evaluation (D0150) on March 17, 2021 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service September 27, 2021.
You asked the Plan to pay for procedure code 62320. You say that this service was billed correctly and should be paid. The Plan denied your request. The Plan says despite multiple requests, you have failed to provide medical records that would support the medical necessity of this service.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. In this case, the Plan has requested medical records from your multiple times to show that these services were appropriate. To date, you have not provided these records. Without this documentation, neither the Plan nor our organization can determine the appropriateness of these services. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of service September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service August 23, 2021.
You asked the Plan to pay for procedure code 62320. You say that you billed this service correctly and it should be paid. The Plan denied your request. The Plan says despite multiple requests, you have failed to provide medical records that would support the medical necessity of this service.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. In this case, the Plan has requested medical records from you multiple times to show that these services were appropriate. To date, you have not provided these records. Without this documentation, neither the Plan nor our organization can determine the appropriateness of these services. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of service August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $45 copayment for Provider and Professional Services in an in-network specialist's office. You can find this information on pages 83 to 84 of the Plan's 2021 Evidence of Coverage (EOC). 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 $45 copayment for Provider and Professional Services in an in-network specialist's office. You have been asked to pay a $45 copayment for a specialist office visit. A 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 a specialist office visit provided on November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care, per day (99305) rendered by the out-of-network (OON) provider on June 30, 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 only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
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 initial nursing facility care, per day (99305) rendered by the out-of-network (OON) provider on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and
panoramic radiographic image (D0330) provided October 11, 2021, by an out-of-network (OON) dentist.
You asked the Plan to pay for the limited oral exam and panoramic x-ray. You say that you feel the services
should be covered because it wasn't an ordinary dentist visit. The Plan denied your request. The Plan says you
have exceeded the frequency limit for the limited oral exam and your panoramic x-ray has processed correctly.
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 limited
oral exam once per plan year and the panoramic x-ray once every three plan years. If you choose to see an
OON dentist you might be billed for charges above what the Plan pays, even for services listed as $0
copayment.
We looked at the file, and Medicare rules. The Plan provided documentation showing that a limited oral exam
was previously covered on April 2, 2021. Based on this information, we decided that the Plan's frequency limit
for coverage of the limited oral exam has been exceeded. The Plan also provided documentation showing that
the full allowed amount for the panoramic x-ray was covered. You are responsible for the difference between
the allowed amount and the total cost charged by the OON provider. Therefore, we decided that the Plan does
not have to pay for the limited oral evaluation - problem focused (D0140) and panoramic radiographic image
(D0330) provided October 11, 2021, by an out-of-network (OON) dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), prophylaxes (D1110), periodic oral evaluation (D0120), resin-based composite (D2391), first intraoral periapical x-ray (D0220), and two additional intraoral periapical x-rays (D0230 x2) provided on May 6, 2021, and November 8, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, prophylaxis, periodic oral evaluation, resin-based composite, and intraoral periapical x-rays. You say that the dentist you were treated by shows as in-network per the Plan's provider search tool. You also say that the dentist confirmed they were in-network before the services were rendered. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does 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.  Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), prophylaxes (D1110), periodic oral evaluation (D0120), resin-based composite (D2391), first intraoral periapical x-ray (D0220), and two additional intraoral periapical x-rays (D0230 x2) provided on May 6, 2021, and November 8, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can receive services at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a virtual colonoscopy (computed tomography
colonography) for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are medically necessary and should
be authorized. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that CT colonography is not covered at this time.
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 services. Our reviewer says that
Our physician reviewer found
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 pre-approve a virtual colonoscopy (computed
tomography colonography) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from August 1, 2020, to 
August 5, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed DRG is not 
supported.
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 diagnosis code N17.0. 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 use of diagnosis code N17.0 is 
not supported by the records provided. Our physician reviewer found that there is no evidence in the medical 
record documentation supporting that this enrollee had sepsis, shock, toxin exposure or that the enrollee 
suffered any marked hypotension beyond the transient positive orthostatic vital signs. It is maintained that 
acute tubular necrosis is a serious, organ-threatening complication of renal injury that has potential to evolve 
into long-term, permanent kidney damage. Also, it is maintained that further treatment, monitoring and 
evaluation of acute tubular necrosis would include significantly more resources and interventions than 
maintenance intravenous fluids and daily, routine metabolic profile blood studies. 
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 the inpatient services provided from August 1, 2020, to August 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urine PCR testing provided on October 22, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that urine PCR amplification techniques raise considerable concerns regarding contamination from one specimen to another, creating the potential for false-positive results.
The clinical interpretation of PCR results may also be challenging. Amplification of organisms representing latent infection or colonization cannot be distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation. Finally, specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large groups of patients for many of the microorganisms. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the urine PCR testing provided on October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on October 18, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that that you believe the Plan has improperly processed this claim. You also say on April 12, 2021 you had a dental checkup performed at this same dental office and the claim was processed as in-network by the Plan. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does 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.   Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on October 18, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from September 30, 2021, to October 3, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be covered and you refuse to pay. 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 $255 copayment per day for days 1-5 of Inpatient hospital care.
You have been asked to pay a $675 copayment for three days of inpatient hospital care ($225 x 3 = $675). 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 September 30, 2021, to October 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 18, 2021.
You asked the Plan to pay for the dental service. You say that you have not been to the dentist at all this year. You say that this should be covered. You also say that the last time you were at the dentist was in 2019. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation is not a preventive dental service and therefore is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning (D1110) and oral exam (D0120) provided on 
November 18, 2021 by the out of network dentist.
You asked the Plan to pay for the dental services. You say that you have been seeing this dentist for 10 years. 
You say that you have never been billed for dental services. You also say that you cannot afford to pay this.
The Plan denied your request. The Plan says dental services that you receive 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 and the services are listed as covered, 
dental services received out of network are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the cleaning (D1110) and oral exam (D0120) 
provided on November 18, 2021 by the out of network dentist
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cardiovascular screening services (81404, 81442 and 81479) provided on June 10, 2021.  You asked the Plan to pay for the cardiovascular screening services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support Medicare criteria for coverage.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, the cardiovascular screening services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, this testing does not meet Medicare's definition of covered cardiovascular risk assessment testing and the place of service code billed does not appear appropriate for the services rendered. Therefore, we decided that the Plan does not have to pay for the cardiovascular screening services (81404, 81442 and 81479) provided on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited (problem-focused) oral exam (D0140) provided on October 20, 2021.
You asked the Plan to pay for the limited exam. You say that this service was necessary to evaluate a new problem. The Plan denied your request. The Plan says you had a previous limited oral exam on May 10, 2021, which was covered by the Plan at that time. This type of exam is limited to one per year under your dental benefit. Therefore, the exam in question exceeds the frequency limitation of your benefit and will not be 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. The Plan can cover one limited oral evaluation (D0140) per calendar year. Though the Plan offers a dental benefit in excess of Medicare coverage, the limited exam is requested in a frequency that is not covered under this benefit. Documentation shows that the Plan has already covered a previous limited oral exam for you in 2021. Therefore, we decided that the Plan does not have to pay for the limited (problem-focused) oral exam (D0140) provided on October 20, 2021.