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

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), panoramic x-ray (D0330), and periapical x-rays (D0220, D0230) provided on June 16, 2021.  You asked the Plan to pay for the dental services. You say that you advised that you did not want any services that were not covered. You say that you have received 2 different bills for the same services in different amounts. You also say that you were advised you would not have to pay anything out of pocket. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that the comprehensive oral evaluation you received on May 26, 2020, was paid. The Plan says that the provider in this case is out of network. The Plan also says that out of network dentists may bill you for any amount greater than what the plan pays.  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.  We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the frequency limit has been exceeded for the comprehensive oral evaluation. Additionally, out of network dentist may bill you for any amount greater than what the plan pays. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), panoramic x-ray (D0330), and periapical x-rays (D0220, D0230) provided on June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for periapical x-ray (D0220), the osseous surgery (D4261), biologic materials to aid in tissue regeneration (D4265), and the bone graft of peri implant defect (D6103) provided on July 15, 2021.  You asked the Plan to pay for the dental services. You say that you would lose this molar without these services. You say that losing that tooth would make it hard to chew food. You also say that you have been going to this periodontist for over 10 years and trust him. The Plan denied your request. The Plan says the dental services you received are not listed as covered. The Plan also says that 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, the requested items or services are not among those covered under this benefit. Additionally, although periapical x-ray is listed as covered, dental services received out of network are not covered. Therefore, we decided that the Plan does not have to pay for periapical x-ray (D0220), the osseous surgery (D4261), biologic materials to aid in tissue regeneration (D4265), and the bone graft of peri implant defect (D6103) provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308, 99309, 99310) rendered by the out-of-network (OON) provider from August 2, 2021, through August 9, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 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 subsequent nursing facility care, per day (99308, 99309, 99310) rendered by the out-of-network (OON) provider from August 2, 2021, through August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for urgently needed services provided on July 30, 2021.  You asked the Plan to waive the copayment for urgently needed services. You say that you were told that you would not owe a copayment for the second visit and would not have went if you had known you would have to pay. 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 $65 copayment for urgently needed services.   You have been asked to pay a $65 copayment for urgently needed services. Urgently needed 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 urgently needed services provided on July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye exam (92014) provided on August 2, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the eye exam. You say that you did not realize this provider was out-of-network. The Plan denied your request. The Plan says out-of-network care is only covered in limited circumstances. There is no documentation that the eye exam was urgent or emergent, and there were in-network providers who could have performed this care. In addition, this provider is not part of the Plan's routine supplemental vision 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 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 eye exam (92014) provided on August 2, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an office visit provided on February 1, 2021.  You asked the Plan to waive the coinsurance for an office visit. You say that you disagree with the charges. 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 35% coinsurance for out-of-network physician/practitioner services, including doctor's office visits. You had an office visit with an out-of-network provider on February 1, 2021. Therefore, you are responsible to pay your share of the out-of-network cos-sharing charges. The total allowed amount is $126.04 and 35% of that is $44.11. Please note that the other dates of service in your appeal request are being handled separately by the Plan.   You have been asked to pay the total coinsurance amount of $44.11 for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 an office visit provided on February 1, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for continued SNF services after February 1, 2021.
You asked the Plan to pay for SNF care. The Plan denied your request. The Plan says that the requested service is not medically necessary.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before February 1, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pay for continued SNF services after February 1, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from May 14, 2021, to May 16, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says that the inpatient care 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 based on the severity of the enrollee's condition and sufficient evidence to support acute coronary syndrome (ACS), it was expected that the enrollee would require hospital services that would likely cross 2 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 May 14, 2021, to May 16, 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 the Plan does not have to pay for out of network physician services provided on April 29, 2021.  You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services provided on April 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Intracept procedure.  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 items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is considered experimental in nature, as more research is needed to support efficacy. 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 an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve orthopedic treatment with a tertiary level of care provider.  You asked the Plan to pre-approve orthopedic treatment. You say that the enrollee needs to be treated by this provider due to her condition. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee does not need to be treated at the tertiary level of care and can be treated by a community-level provider instead.  Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs.   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 orthopedic treatment. Our reviewer says that the enrollee does not meet the Medicare criteria for treatment at the tertiary level of care. Our physician reviewer found the Plan is offering adequate care to meet the enrollee's medical needs through referral to a community-level provider. There is not anything unique about the enrollee's condition that would make it medically necessary to receive treatment from a tertiary-level provider. The Plan has community-level providers who meet the standards of care required for treatment 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 tertiary-level orthopedic treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve orthopedic treatment with a tertiary level of care provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for an infectious disease screening (0241U) provided on July 16, 2021.  You asked the Plan to pay for an infectious disease screening. You say that this is supported in the records. The Plan denied your request. The Plan says this is not a covered screening service.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, an infectious disease screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for an infectious disease screening (0241U) provided on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Tempus Gene Panel provided to the enrollee on June 27, 2021.  You asked the Plan to pay for the services. You say that a failure to obtain authorization is not justifiable in this instance as a denial reason. The Plan denied your request. The Plan says the services rendered require prior authorization.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this type of gene testing does not yet have sufficient high quality data to supports it leading to clinically significant improvements in overall outcomes (death) compared to treating without the testing for this clinical situation. Therefore, this request for Tempus Gene Panel will be considered not medically necessary at this time.   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 services have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel provided to the enrollee on June 27, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  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 continuation of SNF services is not recommended by physical therapy, occupational therapy or doctors.  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 your condition does not meet Medicare criteria for continued 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 continued skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that that the services you require can safely be received at a different 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 care. Our reviewer says that SNF care is medically reasonable and necessary. You do not have documented skilled nursing needs. You do have documented skilled therapy needs. You are noted to be functioning below your baseline. The documentation does not yet establish that you have reached a new plateau in function. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of your condition. Our physician reviewer found that your condition meets Medicare criteria for SNF care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory service (87631) rendered by the out-of-network (OON) provider on May 24, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (87631) rendered by the out-of-network (OON) provider on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).  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 RFA 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 enrollee has chronic low back pain and had diagnostic bilateral medial branch blocks at L4 to L5 on December 2, 2020 and July 2, 2021. She achieved 50 percent pain relief each time. The Medicare criteria require at least 80 percent pain relief from each set of diagnostic blocks. The criteria for coverage are not met; therefore, the RFA is not reasonable or medically necessary at this time.  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 radiofrequency ablation (RFA).