Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia services (00530) provided July 22, 2021.  You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code is not separately payable.  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 00530 is not supported in the medical record. Specifically, the record shows the enrollee was an inpatient at the time services were provided. Payment is included in inpatient payment. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (00530) provided July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost share amount for the intraoral x-ray image of the entire mouth (D0210), and comprehensive periodontal evaluation (D0180) provided from November 9, 2020, to November 1, 2020.  You asked the Plan to waive the cost share amount for the dental services. You say that preventive dental services are covered. The Plan denied your request. The Plan says you pay 50% coinsurance for Class 2 Basic services including periodontal cleaning and intraoral x-ray image of the entire mouth. The Plan also says that the claim was 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.  Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, there is a 50% coinsurance that applies to Class 2 Basic services, including periodontal cleaning and intraoral x-ray image of the entire mouth. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the cost share amount for the intraoral x-ray image of the entire mouth (D0210), and comprehensive periodontal evaluation (D0180) provided from November 9, 2020, to November 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in another setting, such as a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve the inpatient psychiatric hospital services. You say that your health and safety needs require a continuation of inpatient care. The Plan denied your request. The Plan says the enrollee no longer meets the criteria for an inpatient level of care. The Plan says that the enrollee's mental health needs can be met at less restrictive levels of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on January 14, 2021 with Adjustment Disorder with Depressed Mood. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The enrollee was showing medical symptoms including fluid retention which was deferred to medical. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. The enrollee could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations,
delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth physician visit provided on August 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician visit. You say that authorization should not be needed under telemedicine for payment of services rendered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the telehealth physician visit provided on August 13, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the spinal canal and contents, cervical; without contrast material (72141) rendered by the out-of-network (OON) provider on August 11, 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 magnetic resonance imaging (MRI) of the spinal canal and contents, cervical; without contrast material (72141) rendered by the out-of-network (OON) provider on August 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional physical therapy for the enrollee.  You asked the Plan to provide coverage for these services. You say that these services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 provide coverage for these services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition.  Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to provide treatment safely and effectively, that the services can be safely and effectively performed only by or under the supervision of a therapist. The patient has been instructed in and is independent in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.  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 provide coverage for additional physical therapy for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the implant/abutment supported removable denture (D6111) and precision attachments (D5862) provided on August 23, 2021.  You asked the Plan to pay for the dental services. You say that these services were beneficial for the enrollee. The Plan denied your request. The Plan says these services are not covered by the Plan's dental 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.  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 implant/abutment supported removable denture (D6111) and precision attachments (D5862) provided on August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the filling (D2393) for tooth # 4 provided on August 3, 2021.  You asked the Plan to pay for the filling. You say that it appears you have 2 totally different dental plans from the same carrier. You say that you have had several procedures done and paid over $1,000. You say that you owe $315. You also say that the plan should cover this. The Plan denied your request. The Plan says 2 fillings per calendar year are covered. 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 fillings are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for 2 fillings that you received on July 13, 2021. Therefore, we decided that the Plan does not have to pay for the filling (D2393) for tooth # 4 provided on August 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from June 18, 2019, to July 10 2019.
You asked the Plan to waive the copayment for a SNF stay. You say that you were told that the Plan would not cover anything past July 9, 2020, so the enrollee was discharged. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day for days 1-20 and a $172 copayment for days 21-100 for SNF care. The enrollee had a SNF stay from June 18, 2019, to July 10, 2019. The enrollee is not being charged a copayment for days 1-20 (June 18, 2019, to July 7, 2019). The enrollee is responsible to pay a $172 for days 21-22 (July 8, 2019, to July 9, 2019). The total amount the enrollee owes is: $172 (copayment) x 2 (SNF days) = $344. The enrollee has been asked to pay the total copayment amount of $344 for a SNF stay. A SNF stay falls within the SNF care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay provided from June 18, 2019, to July 10 2019.
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 you need more skilled therapy. The Plan denied your
request. The Plan says medical records do not support the need for an intensive rehabilitation therapy program.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 health plan's denial should be upheld. The enrollee does not require the intensity
of services provided at an IRF. Specifically, the enrollee is not shown to require or to be able to tolerate fifteen
hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be
met 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 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve below the knee compression stockings 30-40 mm Hg for the enrollee.  You asked the Plan to pre-approve the stockings. You say that this is medically necessary. The Plan denied your request. The Plan says this is covered in the treatment of an open venous stasis ulcer.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the stockings. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no clinical documentation from ordering provider. There is no evidence of a diagnosis of venous stasis ulcers documented to bilateral lower extremity edema. The review has determined that there is no documentation that the enrollee has a qualifying wound or an open venous stasis ulcer.       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 stockings have not been met. Therefore, we decided that the Plan does not have to pre-approve below the knee compression stockings 30-40 mm Hg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) provided on August 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you ask that the plan not penalize the doctor for the hospital staffs failure in taking the proper steps to obtain authorization and reconsideration of this claim for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) provided on August 6, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a diagnostic mammography provided on August 23, 2021. We also decided that the Plan does not have to waive the copayment for the X-rays provided on August 23, 2021.  You asked the Plan to waive the copayment for the diagnostic mammography. You also asked the Plan to waive the copayment for the X-rays. You say that you were informed by the provider that this was a preventative mammogram. 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 $100 copayment for diagnostic tests provided at an outpatient hospital.   Your contract with the Plan also clearly says that you must pay a $50 copayment for X-rays provided in an outpatient hospital.  You have been asked to pay $73.96, which is less than the $150 combined copayments for the diagnostic mammography and the X-rays. The diagnostic mammography and the X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 diagnostic mammography provided on August 23, 2021. We also decided that the Plan does not have to waive the copayment for the X-rays provided on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shingles vaccine provided on December 10, 2020 and April 19, 2021.  You asked the Plan to pay for the shingles vaccine. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the shingles vaccine is not covered under your Medicare Part B benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on December 10, 2020 and April 19, 2021.   Benefits for the shingles vaccine 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: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the full sequence gene analyses (81295, 81298, and 81317), targeted sequence gene analysis (81309), molecular pathology procedure (81401), and translocation analysis (81194) provided on August 3, 2021.    You asked the Plan to pay for the full sequence gene analyses, targeted sequence gene analysis, molecular pathology procedure, and translocation analysis. You say that the doctor regarded these services as a medically necessary and valuable tool when determining treatment for the enrollee. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the full sequence gene analyses (81295, 81298, and 81317), targeted sequence gene analysis (81309), molecular pathology procedure (81401), and translocation analysis (81194) provided on August 3, 2021.