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 admission to an IRF is medically necessary, and the enrollee would benefit from skilled therapy services. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The care required by the enrollee can be provided in an alternate 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 that based on the enrollee's current medical stability and lack of medical complexity, there is no need for physician supervision at least three times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee has no major comorbidities, and no acute rehab nursing needs are noted in the record. At the current functional level, ambulating household distance, the enrollee does not require intensive therapies consisting of at least three hours of therapy per day at least five days per week with a multidisciplinary approach to daily therapy. IRF admission is not medically necessary based on lack of medical complexity and high functional level. Document does not support the necessity for admission to IRF. While the enrollee may benefit from continued physical and occupational therapies, his rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on June 18, 2021.
You asked the Plan to pay for the consultation. You say that you believe this service should be covered as a dental office visit that should have a 20% coinsurance. The Plan denied your request. The Plan says this service is not a covered benefit 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 consultation (D9310) provided on June 18, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 23, 2021 to August 25, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care provided from August 23, 2021 to August 25, 2021 was medically necessary. The Plan denied your request. The Plan says that the inpatient hospital care provided from August 23, 2021 to August 25, 2021 was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was evaluated in the emergency department (ED) on August 23, 2021 for altered mental status in the setting of known liver disease, need for intermittent drainage of fluid in the abdomen (paracentesis for ascites) and recent placement of a drainage tube (biliary stent). He was evaluated and admitted and received IV antibiotics, underwent paracentesis, had tests and was given a medication to encourage bowel movements (Lactulose). His condition stabilized and improved, and he was discharged home on August 26, 2021. The review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from August 23, 2021 to August 25, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for facet joint injections (64494) provided on July 28, 2021.
You asked the Plan to pay for facet joint injections. You say that this is supported in the records. The Plan denied your request. The Plan says this exceeds MUE.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pay for facet joint injections (64494) provided on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on June 25, 2021.
You asked the Plan to pay for the dental service. You say that every 6 months you receive a denial of payment for periodontal evaluations that you have received for the last 20 years. You say that your treatment plan includes a periodontal evaluation and maintenance every 6 months. You also say that you have had issues getting this covered since you switched to this plan. The Plan denied your request. The Plan says the comprehensive periodontal evaluation is not listed as a covered service. The Plan says that this service was paid for date of service May 9, 2020, as a one time exception. The Plan also says that you were notified that no further benefits would be available for this service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 comprehensive periodontal evaluation (D0180) provided on June 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the brain you had on August 2, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you do not understand why you are being charged for this. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $150 copayment for diagnostic radiology services. You have been asked to pay a $150 copayment for the MRI. The MRI falls within the diagnostic radiology 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 the magnetic resonance imaging (MRI) of the brain you had on August 2, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost-share for the ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete (76770) and ultrasound, pelvic (non-obstetric), real time with image documentation; complete (76856) provided December 3, 2018.
You asked the Plan to reduce the cost-share for the ultrasounds. You say that you feel you should be charged $20 per service. The Plan denied your request. The Plan says the coinsurance was applied correctly.
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 each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or a free-standing facility. You have been asked to pay $15.78 ($78.90 x 20% coinsurance = $15.78) for the ultrasound behind your abdominal cavity and $9.89 ($49.47 x 20% coinsurance = $9.89) for the ultrasound of your pelvis. The ultrasounds 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 reduce the cost-share for the ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete (76770) and ultrasound, pelvic (non-obstetric), real time with image documentation; complete (76856) provided December 3, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for X-rays provided on February 8, 2020.
You asked the Plan to waive the deductible for X-rays. You say that you were not informed that you would owe anything. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible which applies to out-of-network outpatient diagnostic tests and therapeutic services and supplies. You received X-rays at an out-of-network provider on February 8, 2020. The record shows that you had paid $0 toward the $1,000 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $129.63. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $1,000 deductible which applies to out-of-network outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time X-rays was received on February 8, 2020. Therefore, we decided that the Plan does not have to waive the deductible for X-rays provided on February 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on August 23, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the ambulance responded to your residence because you were unconscious, and your blood sugar had dropped to 34. You also say that the crew checked your blood sugar, treated you with glucose gel, asked if you wanted to go to the hospital, and you said no. The Plan denied your request. The Plan says the ambulance charges are not covered because there was no transport.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 23, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on August 23, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction services provided August 25, 2021.
You asked the Plan to pay for the eye services. You say that in order to have cataract surgery, it was necessary for you to have a refractive exam by your cataract surgeon. The Plan denied your request. The Plan says the eye refraction service is not a covered benefit since it was rendered as a part of a medical vision check.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when performed by a participating provider and performed during a routine exam. We looked at the file and the Plan's rules. eye refraction is covered when performed by a participating provider and performed during a routine exam. Based on this information, we decided that the Plan's rules for coverage of the eye services have not been met. Therefore, we decided that the Plan does not have to pay for eye refraction services provided August 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on August 4, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that you never paid for CT scans with your previous Plan and were not informed that you would owe a copayment when you switched Plans. The Plan denied your request. The Plan says the claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay a $125 copayment for diagnostic radiology services. You have been asked to pay a $125 copayment for a CT scan. A CT scan 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 provided on August 4, 2021.
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 August 23, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that initially x-rays were taken by one provider in July. You also say that when you went back on August 23, 2021, the original provider was on vacation and the treating provider needed to take new x-rays so he could see the problem. 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 July 15, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve peripheral nerve block injections.
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 peripheral nerve blocks are 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 tarsal tunnel syndrome in both legs. The use of peripheral nerve blocks for the treatment of your condition is considered investigational in nature. The services are therefore not reasonable or medically necessary. 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 peripheral nerve block injections
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and intraoral x-ray (D0210) provided on March 30, 2021.
You asked the Plan to pay for the comprehensive oral evaluation (D0150) and intraoral x-ray (D0210). You say that you went to see this dentist to clean your tooth and then went to another in-network dentist. You say that you cannot afford to pay and need help resolving the bill. The Plan denied your request. The Plan says these services are only covered once every three plan years.
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 also have a maximum benefit of one comprehensive oral evaluation (D0150) and intraoral x-ray (D0210) every three plan years. The Plan received the claim for the comprehensive oral evaluation and intraoral x-ray provided on April 19, 2021 prior to receiving the claim for the services provided on March 30, 2021. The Plan paid for the comprehensive oral evaluation (D0150) and intraoral x-ray (D0210) provided on April 19, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and intraoral x-ray (D0210) provided on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on September 3, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that you do not understand why you were told there would be no charge for the x-ray but are being billed for this procedure. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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, panoramic x-ray (D0330) is limited to one procedure every three plan years. The record shows that you received a panoramic x-ray (D0330) on August 28, 2019 and your panoramic x-ray (D0330) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on July 8, 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 the services are not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. The records do not show that the enrollee was injured or directly exposed to any illness related to the TDaP vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on July 8, 2021.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an interrogation device evaluation (93295, 93296) provided on August 15 to August 18, 2021, by an out-of-network provider.
You asked the Plan to pay for an interrogation device evaluation. You say that the medically necessary services at issue were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 an interrogation device evaluation (93295, 93296) provided on August 15 to August 18, 2021, by an out-of-network provider