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

 We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on October 12, 2021.  You asked the Plan to pay for the limited exam. You say that you assumed you would be reimbursed for these necessary services. The Plan denied your request. The Plan says they have agreed to pay for the extraction; however, the limited oral evaluation is not a covered service under your dental benefit. You signed a treatment plan at the provider's office prior to services that indicated that there was no coverage for this service, and you would be fully responsible for the charges.  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 exam (D0140) provided on October 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.  You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says your condition has improved.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   Continued inpatient services from February 23, 2022, forward were requested. 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 continued services. Our physician reviewer found that active treatment was not taking place beyond the date in question. It did not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis.  A review of the records show that you do not meet the criteria for continued acute inpatient mental health treatment as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations. You were cooperative/compliant with treatment. You were not showing any aggressive behaviors or any treatment required for acute threats of 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan.  You asked the Plan to pre-approve PET scan. You say that the enrollee has prostate cancer and doctors need to know whether the cancer has spread to design the best treatment. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because PET to evaluate for metastatic prostate cancer to lymph nodes prior to oncological treatment is not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the enrollee does not meet the Medicare criteria for this PET scan. Our physician reviewer found the record indicates that the enrollee is newly diagnosed with prostate cancer and has not undergone treatment. PET is nationally non-covered for initial anti-tumor treatment strategy in beneficiaries who have adenocarcinoma of the prostate.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on August 10, 2021.  You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed. 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 70450 is a column II code to column I code 70496. 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 the CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on August 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance transportation services provided on August 29, 2021.  You asked the Plan to waive the copayment for the ambulance trip. You say that you did not request the ambulance and did not have a choice. 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 $275 copayment for each one-way ambulance transport.     You have been asked to pay a $275 copayment for the ambulance trip. The ambulance trip falls within the Ambulance 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 ambulance transportation services provided on August 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that the enrollee needs rehabilitation to return to assisted living. The Plan denied your request. The Plan says the enrollee does not require daily skilled services in a SNF setting.  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 physician reviewer found that the enrollee is at an independent assist level with rolling, sitting up, standing up and transfers. He is at supervision for bathing and toileting, setup for dressing, and independent for ambulation. He does not have documented skilled nursing or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a pain
management specialist on September 23, 2021.

You asked the Plan to waive the copayment for the specialist visit. You say that your copayments are supposed
to be $0. 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 $45
copayment for specialist visits.

You have been asked to pay a $45 copayment for the specialist visit. his 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 office visit you had with a pain management specialist on September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services provided by an opt-out provider on June 23, 2021.  You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendering dentist has opted out of Medicare.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. The rendering dentist has opted out of Medicare until September 2, 2022. Therefore, we decided that the Plan does not have to pay for dental services provided by an opt-out provider on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for office visits provided on September 20, 2021, to October 1, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the office visits. You say that the services were provided with no adequate time frame to obtain authorization. You say the services are medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  

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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for office visits provided on September 20, 2021, to October 1, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal implants (D6010) and bone graft at time of implant placement (D6104).  You asked the Plan to pre-approve the endosteal implants and bone graft. You say that you need these dental implants to have a better way to live. The Plan denied your request. The Plan says these services are not covered under 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal implants (D6010) and bone graft at time of implant placement (D6104).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a prosthetic arm provided on August 30, 2021.  You asked the Plan to waive the coinsurance for the prosthetic arm. You say that the services should be covered. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Prosthetic devices and related supplies.   You have been asked to pay a 20% coinsurance for a prosthetic arm (total allowed is $9,741.58 x 20% = $1,948.31). Prosthetic arms fall within the Prosthetic devices 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 prosthetic arm provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (98943) provided October 21, 2021.  You asked the Plan to pay for the chiropractic service. You say that you have been going for therapy twice a week and then you received a denial letter. The therapy has helped you tremendously. The Plan denied your request. The Plan says Medicare does not cover chiropractic treatments to extraspinal regions (98943) which includes the head, upper and lower extremities, rib cage and abdomen.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.          The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (98943) provided October 21, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 29, 2021.

You asked the Plan to pay for the laboratory services. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on September 10, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for laboratory services provided on September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on November 9, 2021.  

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 requested 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 services provided to you by an out-of-network provider on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal implants (D6010 x2) and two surgical accesses to an implant body (D6011 x2).  You asked the Plan to pre-approve the endosteal implants and surgical accesses. You say that you want to be rehabilitated with implants in areas 30 and 31 to restore your chewing ability on the right side with a fixed prosthesis. The Plan denied your request. The Plan says the criteria is not met. The Plan also says that implant services covered under your policy are for the purpose of attaching a complete denture in completely edentulous (toothless) patients.  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 implant benefit covers only the dental implant to hold a complete denture. The provided documentation shows that you are requesting these implant services in order to make a fixed prosthesis, which is not covered under your benefit plan. Therefore, we decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal implants (D6010 x2) and two surgical accesses to an implant body (D6011 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the four resin-based composites of one surface (D2330 x4) provided on August 4, 2021.  You asked the Plan to pay for the four resin-based composites. You say that this claim was paid OON fees, and you have a letter stating the treating provider was in-network since July 23, 2021. You also say that the Plan says that the doctor's effective date is August 6, 2021 and you would like this to be investigated. The Plan denied your request. The Plan says the enrollee's benefits for this service have been satisfied and the frequency limitation 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, restorations are limited to two procedure codes per calendar year. The record shows that the enrollee received 8 resin-based composites on August 4, 2021, four of which were covered by the Plan, and the enrollee's restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the four additional resin-based composites of one surface (D2330 x4) provided on August 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scan of the lumbar spine (72148).  You asked the Plan to pre-approve MRI scan of the lumbar spine. You say that this imaging service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI scan of the lumbar spine. Our reviewer says that the requested MRI services are not medically reasonable and necessary. Our physician reviewer found that the patient is an 82-year-old male with chronic low back pain. It was reported that the patient tried home stretches and walks but has not tried formal physical therapy (PT). MRI lumbar spine was requested. Due to the criteria requiring a full course of PT for the patient's low back pain and no recent evidence of a red flag diagnosis to justify early consideration for MRI, the MRI will be considered not 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 MRI scan of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scan of the lumbar spine (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for an office visit provided on October 4, 2021.  You asked the Plan to waive the deductible for the office visit. You say that you made an appointment with one provider, but you were seen by an out-of-network provider instead. 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. Your contract with the Plan says that there is $750 deductible which applies to office visits.              The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefits category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which applies to an office visit. This deductible applies to office visits for both in and out-of-network providers. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on October 4, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on October 4, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not require daily skilled services in a SNF setting.  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 physician reviewer found that you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are walking household distances and tending to activities of daily living with minimal supervision.  A reported ankle fracture is not documented. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. At this point, your care needs are custodial.  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.