Persius/hicric huggingface dataset:
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 this is medically necessary. The Plan denied your request. The Plan says the care could be received in another setting.  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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical management of an odontoid fracture and non-surgical management of a humerus fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 25, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 25, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites (D2331 x2) and consultation (D9310) provided on May 3, 2021 by a sanctioned provider.
You asked the Plan to pay for the resin-based composites and consultation. You say that if there are certain dentists that are not accepted you should have been notified. The Plan denied your request. The Plan says these services were rendered by a sanctioned dental provider. The Plan also says that the Health Plan is unable to issue payment due to Federal regulations.
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. Medicare rules say that the Secretary shall exclude any individual or entity which has been suspended or excluded from participation, or otherwise sanctioned, under any Federal program, including programs of the Department of Defense or the Department of Veterans Affairs, involving the provision of health care, or a State health care program for reasons bearing on the individual's or entity's professional competence, professional performance, or financial integrity from participation in any Federal health care program 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. We found that the treating provider was excluded from participating in federal programs at the time these services were performed. Therefore, we decided that the Plan does not have to pay for the two resin-based composites (D2331 x2) and consultation (D9310) provided on May 3, 2021 by a sanctioned provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride excluding varnish (D1208)
provided on September 3, 2021.
You asked the Plan to pay for the topical application of fluoride excluding varnish. You say that you called
several times and were told the provider was in-network. You also say that you feel you should not be held
responsible for this bill. The Plan denied your request. The Plan says this service is not a covered expense
under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
topical application of fluoride excluding varnish (D1208) provided on September 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.  You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the required services are custodial care.  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 the admission. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case.  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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on August 6, 2021.
You asked the Plan to pay for a pneumatic compression device. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for PCDs have not been met.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on August 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on August 11, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the appropriate modifier was not billed in this case.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76770 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for ultrasound services provided to the enrollee on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for senior living services received from April 30, 2021, to June 10, 2021.
You asked the Plan to pay for the services. You say that the provider is not contracted with the plan or certified for Medicare. The Plan denied your request. The Plan says these claims are submitted because there were out-of-pocket costs that were incurred when skilled nursing facility benefits were terminated prematurely.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. You are not eligible to bill Medicare. The Plan did not pre-approve the services. 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 senior living services received from April 30, 2021, to June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 2 fillings provided on September 23, 2021, by the out of network dentist.
You asked the Plan to pay for the dental services. You say that you were not aware that going to an out of network dentist would be more costly. You say that you are not happy with the allowed amount. You also say that you are not happy with the amount paid on the claim either. The Plan denied your request. The Plan says there is a 50% coinsurance for fillings when performed out of network. The Plan also says that out of network dentists may bill you for any balances over the allowed amount in addition to any coinsurance amount.
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, there is a 50% coinsurance when received out of network. Additionally, out of network dentists may bill you for any balances over the allowed amount in addition to any coinsurance amount. 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 pay for 2 fillings provided on September 23, 2021, by the out of network dentist.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis (74178) provided on August 20, 2021.  You asked the Plan to waive the copayment for a CT scan of the abdomen and pelvis. You say that the Plan's customer service told you that the procedure at issue was totally covered. The Plan denied your request. The Plan says the correct copayment 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 a $350 copayment for CT scans.   You have been asked to pay a $350 copayment for a CT scan of the abdomen and pelvis. A CT scan of the abdomen and pelvis falls 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 CT scan of the abdomen and pelvis (74178) provided on August 20, 2021.   Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibilities from a representative of the Plan 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Levemir.
You asked the Plan to pre-approve Levemir. You say that the records provided support the medical necessity of the requested drug. The Plan denied your request. The Plan says the drug is being requested through the pharmacy. The Plan says that the requested drug is injected twice daily at home and is considered self-injectable.
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 Levemir.
Benefits for Levemir 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 13, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you received a regular evaluation from your regular dentist who referred you to an oral surgeon. You also say that this evaluation done by the oral surgeon was necessary for him to see and evaluate what was needed for a safe extraction due to your underlying medical issues. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on February 3, 2021 and your problem focused limited oral evaluation (D0140) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy (90837) provided on September 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that no authorization is required for out of network. 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 individual psychotherapy (90837) provided on September 7, 2021 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 the nuclear medicine thyroid diagnostic imaging (78014) provided August 18, 2021.
You asked the Plan to waive the copayment for the imaging service. You say that this was a follow up for a mammogram appointment. You were under the impression that it was for an ultrasound and was not aware that it was going to be a PET scan. You were not prepared for a $250 copay. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage
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 $250 per day for other Medicare covered diagnostic radiology services that are not ultrasounds.
You have been asked to pay $250 for the imaging service. The imaging service falls 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 the nuclear medicine thyroid diagnostic imaging (78014) provided August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture service (97811) provided September 13, 2021.  You asked the Plan to pay for the acupuncture services. You say that you feel that the service should be covered. You have not used more than 7-8 visits and the benefit should be available to you. The Plan denied your request. The Plan says the records do not show that the acupuncture visits were for the treatment of chronic lower back pain. This visit exceeds the limit of the Wellness allowance benefits.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, acupuncture is covered for the treatment of lower back pain. The medical records provided do not show that the acupuncture treatment was for chronic lower back pain. Therefore, we decided that the Plan does not have to pay for the acupuncture service (97811) provided September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2393), onlay (D2643), and indirect pulp cap (D3120) provided on August 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the resin-based composite, onlay, and indirect pulp cap. You say that due to your extensive dental history with this OON provider, you do not wish to change dental providers. You also say that you would like these services to be covered under your 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. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
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 resin-based composite (D2393), onlay (D2643), and indirect pulp cap (D3120) provided on August 17, 2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services (99284) provided on March 9, 2021,
You asked the Plan to waive the copayment for the emergency room services. You say that the services should be covered as you went to the ER for an allergic reaction due to a covid-19 vaccine. 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 $120 copayment for Urgently needed services.
You have been asked to pay a $120 copayment for the emergency room services. There is no Plan or Medicare guidelines stating that ER visits due to allergic reactions would be covered, even if they are result of a Covid-19 vaccine. Emergency room services fall within the Urgently needed services 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 emergency room services (99284) provided on March 9, 2021,
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on March 22, 2021.  You asked the Plan to pay for the complete series of intraoral x-rays. You say that this is the first time you tried using the yearly routine dental services. You also say that you received an inspection of the teeth and many x-rays, which you were not advised would not be covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that there is no record of you contacting the Plan prior to this visit to verify your benefits or coverage.  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 complete series of intraoral x-rays (D0210) provided on March 22, 2021.