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

 We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from May 20, 2021, to May 28, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were kept in the hospital longer than expected because you developed an infection.  You do not think you should have to pay extra for something that was out of your control. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that you only had $1392.18 remaining on your out-of-pocket maximum for the year, so your copayment was limited to this 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 $310 copayment per day for days 1-5, and a $0 copayment for additional days for inpatient hospital care.   Records show that you were in the hospital for eight days.  You were charged a $310 copayment per day for each of the first five days, for a total of $1550.  However, since this exceeds your annual out-of-pocket maximum, your actual assessed cost sharing for this service was capped at $1392.18.  This copayment applies regardless of the reason for the length of your hospital stay. 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 services you received from May 20, 2021, to May 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of Aduhelm.  You asked the Plan to pre-approve Aduhelm. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Aduhelm is not medically reasonable or necessary.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Aduhelm. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Aduhelm. Our physician reviewer found the Food & Drug Administration (FDA) has not approved Aduhelm for the enrollee's condition. The requested use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Aduhelm.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the X-ray services (71046, Q0092, R0070) provided on April 27, 2021.  You asked the Plan to pay for the X-ray services. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says the place of service was inappropriate for the billed services.  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, the CPT Code Manual definition of the denied codes are:  CPT 71046: Radiologic examination, chest; 2 views   Q0092: Set-up portable x-ray equipment  R0070: Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient see  We find that CPT code 71046, Q0092, R0070 are not eligible for payment. Specifically, skilled nursing facilities (SNF) are PPS (Prospective Payment System) and therefore, payment for services rendered would be arranged with the SNF. Based on this information, we decided that Medicare rules for coverage of the X-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the X-ray services (71046, Q0092, R0070) provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on October 26, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for these services. You say that you found the name of the provider online and didn't wait to get authorization. The Plan denied your request. The Plan says the services were 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 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 office visit provided on October 26, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Lumbar-sacral orthosis brace (L0650) provided on March 8, 2021.

You asked the Plan to waive the coinsurance for a Lumbar-sacral orthosis brace. You say that the services should be covered as you inquired about whether the brace was necessary and if all your services would be covered under your copay. The Plan denied your request. The Plan says the coinsurance applied correctly based on the item provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable medical equipment (DME) and related supplies.

You have been asked to pay a 20% coinsurance for a Lumbar-sacral orthosis brace (the allowed amount for this item is $1,223.59, 20% of that is $244.72). Lumbar-sacral orthosis braces fall within the Durable medical equipment (DME) and related 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 coinsurance for a Lumbar-sacral orthosis brace (L0650) provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), removal of residual tooth roots (cutting procedure) (D7250), deep sedation/general anesthesia - first 15 minutes (D9222), and deep sedation/general anesthesia - each subsequent 15 minute increment (D9223) provided August 10, 2020.

You asked the Plan to provide additional payment for the tooth extractions, removal of residual tooth roots, and general anesthesia. You say that you would like the Plan to provide additional payment for the services. The Plan denied your request. The Plan says they have covered 50% of the cost of the requested dental 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. The Plan covers 50% of the cost of tooth extractions, removal of residual tooth roots, and general anesthesia provided out-of-network up to a $1,000 dental allowance.

We looked at the file and Medicare rules. In this case the Plan provided documentation showing that 50% coverage was provided for the out-of-network preventative and comprehensive dental services. This means that you have been asked to pay less than or equal to the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to provide additional payment for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), removal of residual tooth roots (cutting procedure) (D7250), deep sedation/general anesthesia - first 15 minutes (D9222), and deep sedation/general anesthesia - each subsequent 15 minute increment (D9223) provided August 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve cyclobenzaprine for the enrollee.  You asked the Plan to pre-approve cyclobenzaprine under Medicare Part B. You say that this drug is medically necessary. The Plan denied your request. The Plan says self-administered drugs are not covered under Medicare 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 pre-approve cyclobenzaprine for the enrollee.    Benefits for cyclobenzaprine 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the enrollee is too complex for skilled nursing care. You say that the enrollee requires extended and acute-care level interventions provided by complex care trained staff, interdisciplinary treatment and team driven rehabilitation to resume reconditioning and improvement. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee can continue to get care at the current hospital until ready for discharge to a lower level of care.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to the acute care hospital with acute hypoxic respiratory failure secondary to interstitial ILD and requiring intubation, steroids. Recent note shows the enrollee having been extubated and tolerated high flow oxygen.  Ongoing steroids were planned. The enrollee appears to be improving and weaning appropriately and should only require short-term additional acute care services that can be received safely at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH will be considered not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care should be appropriate soon when treatment has completed.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member has no daily skilled nurse or therapist needs.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (29515) provided January 6, 2021.

You asked the Plan to pay for surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the primary insurer is liable for these services.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment.

Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an explanation of benefits from the primary payer. As the secondary insurer, the Plan cannot be held responsible for surgical services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for surgical services (29515) provided January 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation and intraoral x-ray provided on July 13, 2021.  You asked the Plan to pay for the limited oral evaluation and intraoral x-ray. You say that what you received did not lay out what was covered, and it was unhelpful. You say that you had to pay out-of-pocket and are being punished for doing the right thing. The Plan denied your request. The Plan says the services are not covered 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, 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 limited oral evaluation and intraoral x-ray provided on July 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve computed tomography (CT) services.  You asked the Plan to pre-approve the CT scan. You say that the enrollee has lost weight and the CT scan is ordered to look for the cause. The Plan denied your request. The Plan says the requested CT is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.   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 CT scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no specific clinical rationale for the requested CT scan. There is no documentation of the exam by her provider, blood tests, chest x-ray and other tests.  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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on June 15, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 95908, 95886, and 95937 are not supported.

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, the CPT Code Manual definition of code 95908 is nerve conduction studies; 3-4 studies. The definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). The definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. 

We find that CPT codes 95908, 95886, and 95937 are not supported in the medical record. Specifically, there is no documentation of 3-4 nerve conduction studies to support code 95908. There is no documentation of needle electromyography of the extremity with related paraspinal areas to support code 95886. There is no documentation of neuromuscular junction testing to support code 95937. 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 pay for the testing services rendered on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve out of network chiropractic services.  You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested provided because of the equipment they use. The Plan denied your request. The Plan says this provider is not in network.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. Therefore, we decided that the Plan does not have to pre-approve out of network chiropractic services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the extractions (D7210 x 5) provided on March 17, 2021, by the out of network dentist.  You asked the Plan to reimburse you for the dental services. You say that both in network providers either delayed your care or gave you the run around. You say that you were in excruciating pain with no immediate help from a medical or dental professional. You say that you were recommended this provider by your friend. You say that this was truly an emergency. You also say that you should be reimbursed for these services. The Plan denied your request. The Plan says 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. Therefore, we decided that the Plan does not have to reimburse you for the extractions (D7210 x 5) provided on March 17, 2021, by the out of network dentist.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for electroconvulsive therapy (includes necessary monitoring) (90870) provided on March 19, 2021 to March 21, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for electroconvulsive therapy. You say that you feel that the services should be covered because you have insurance. 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 electroconvulsive therapy (includes necessary monitoring) (90870) provided on March 19, 2021 to March 21, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve blepharoplasty with facial nerve grafting.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary. The Plan must follow Medicare rules. Medicare rules say that blepharoplasty is covered when specific criteria are met.  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 services are not medically necessary. Our physician reviewer found the records show that you have a history of contractions of the facial muscles (synkinesis) and previously underwent surgical procedures. The records show that the requested procedure is to restore normal facial appearance. The criteria for coverage are not met. The records do not establish medical necessity and reasonableness of the requested procedure.  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 blepharoplasty with facial nerve grafting.