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

 We decided that the Plan does not have to waive the copayment for inpatient hospital care you received from August 16, 2021, to August 23, 2021.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that you did everything that your doctors recommended. You said that you have Medicare and health insurance so you should not have to pay this bill. 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 $325 copayment per day for days 1-6, and a $0 copayment for additional days for inpatient hospital care.    Records show that you were in the hospital for 7 days. You were charged a $325 copayment per day for each of the first 6 days, for a total of $1950. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care you received from August 16, 2021, to August 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from August 27, 2021, to September 25, 2021.  You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says there was no daily skilled nurse or therapist need.  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 pay for the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee required (or received) skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide medically necessary and reasonable treatment from 08/27/2021 through 09/25/2021. Daily skilled services were not required (or provided) from 08/27/2021 through 09/25/2021. Occupational therapy was provided three times per week from 09/14/2021 through 09/27/2021. The enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting.  Services in the nursing facility appear custodial in this case from 08/27/2021 through 09/25/2021 with part-time occupational therapy services provided from 09/14/2021 through 09/27/2021.  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 skilled nursing facility (SNF) services provided to the enrollee from August 27, 2021, to September 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for ophthalmology services (92136) provided August 2, 2021.  You asked the Plan to pay for the ophthalmology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.     In this case, the CPT Code Manual definition of code 92136 is Opthalmic biometry by partial coherence interfreometry with intraocular lens power calculation.  We find that CPT code 92136 is not supported in the medical record. Specifically, the procedure report does not describe measurement of biometry and lens power calculation. Based on this information, we decided that Medicare rules for coverage of the ophthalmology services have not been met. Therefore, we decided that the Plan does not have to pay for ophthalmology services (92136) provided August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 3 multiple power option power wheelchair (PWC) and attachments.  You asked the Plan to pre-approve these items. You say that this is medically necessary. The Plan denied your request. The Plan says that the only power option requested was power tilt.  The Plan must follow Medicare rules. Medicare rules say that a Group 3 multiple power option PWC can be covered if the beneficiary meets coverage criteria for a power tilt and recline seating system and the system is being used on the wheelchair or the beneficiary uses a ventilator which is mounted on the wheelchair.   We looked at the file and Medicare rules. In this case, the file indicates a recline seating system was not requested and the enrollee does not use a ventilator. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 multiple power option power wheelchair (PWC) and attachments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the clinical crown lengthening - hard tissue (D4249) provided July 28, 2021.  

You asked the Plan to pay for the clinical crown lengthening. You say that you needed to use a non-participating provider for your services. The Plan denied your request. The Plan says this service is not covered under your benefits.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   

Though the Plan offers dental benefits in excess of Medicare coverage, the clinical crown lengthening is not among those covered services. Therefore, we decided that the Plan does not have to pay for the clinical crown lengthening - hard tissue (D4249) provided July 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to a Long-Term Acute Care Hospital (LTACH).  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted for operative intervention for colovesicular fistula and developed acute hypoxic respiratory failure and sepsis.  The record indicates that the enrollee is improving but still requires acute care services. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services to be provided by an out-of-network (OON) provider.  

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 these services are available at a network facility.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.         

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an electrical connection (E2311) for a power wheelchair for the enrollee.  You asked the Plan to pre-approve the electrical connection. You say that this is medically necessary. The Plan denied your request. The Plan says the upper limb strength and function are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options.  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 the electrical connection. Our reviewer says that the requested electrical connection is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee has  power options of tilt, and power elevating leg rests but the enrollee does not need to control the power options through a joystick. The enrollee's upper extremity strength and function support that the enrollee can control any power options through their own switches.  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 electrical connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an electrical connection (E2311) for a power wheelchair for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), additional intraoral periapical x-ray (D0230), and topical application of fluoride varnish (D1206) provided on October 21, 2021.  You asked the Plan to pay for the comprehensive oral evaluation, additional intraoral periapical x-ray, and topical application of fluoride varnish. You say that this was your checkup, and you have two cleanings per year. The Plan denied your request. The Plan says your annual $1,000 maximum benefit had been exhausted. The Plan also says that the comprehensive oral evaluation 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, the Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on October 21, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), additional intraoral periapical x-ray (D0230), and topical application of fluoride varnish (D1206) provided on October 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the diagnostic hearing test you had on September 30, 2021.  You asked the Plan to waive the copayment for the diagnostic hearing test. You say that you already paid a copayment for the office visit, so there should not be an extra charge for this test. 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 $35 copayment for diagnostic hearing tests.     Records show that on September 30, 2021, you had both an office visit (procedure code 99213) and a diagnostic hearing test (procedure code 92553).  You have been asked to pay a $35 copayment for the diagnostic hearing test. This hearing test is separate and distinct from the office visit you had, so separate cost sharing can apply. 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 diagnostic hearing test you had on September 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient surgery you had at an outpatient hospital facility on April 23, 2021.  You asked the Plan to waive the copayment for the outpatient surgery. You say that you believe you are being charged as an inpatient even though you were only in the hospital for a few hours. The Plan denied your request. The Plan says you were charged the correct cost sharing for outpatient surgery.  The Plan also says that this provider has given you a $15 discount, so you are only being charged $320 for this service.  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 $335 copayment for outpatient surgery in an outpatient hospital facility.    You have been asked to pay a $335 copayment for the outpatient surgery. 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 outpatient surgery you had at an outpatient hospital facility on April 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Feraheme (Q0138).  You asked the Plan to pre-approve Feraheme. You say that Feraheme is medically necessary. The Plan denied your request. The Plan says a trial of Venofer, Infed, or Ferrlecit is required before alternatives can be considered.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Feraheme. Our reviewer says that Feraheme is not medically necessary. Our physician reviewer found the records do not show a trial of the plan preferred drugs or any reason they would be unsafe or ineffective for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme (Q0138).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on June 21, 2021.  You asked the Plan to waive the copayment for the EKG. You say that you should not have a copayment since it was part of your annual wellness visit. 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 $0 copayment for each annual wellness visit. This does not include lab tests or diagnostic tests.  Your contract with the Plan clearly says that you must pay a $30 copayment for non-radiological diagnostic services, including EKG's.   You have been asked to pay a $30 copayment for the EKG. The EKG 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 an electrocardiogram (EKG) provided on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for aquatic therapy services (97113) provided from September 7, 2021, to September 30, 2021.  You asked the Plan to waive the copayment for the aquatic therapy services. You say that the services should be covered as your physical therapist is a specialist. The Plan denied your request. The Plan says the cost-sharing for physical therapy services 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 $25 copayment for Outpatient rehabilitation services.     You have been asked to pay a $25 copayment for eleven aquatic therapy service visits ($25 x 11 = $275). Aquatic therapy services fall within the Outpatient rehabilitation 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 aquatic therapy services (97113) provided from September 7, 2021, to September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the two-year warranty for lenses/frames purchased on September 17, 2021.  You asked the Plan to pay for the warranty. You say that you were led to believe you could receive full reimbursement for these services. The Plan denied your request. The Plan says they have agreed to reprocess your claim and pay for these out-of-network services in a one-time exception. However, you also purchased a two-year warranty for the eyewear, which is not a covered service under your vision benefit, and therefore remains denied.  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.   Though the Plan offers a vision 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 two-year warranty for lenses/frames purchased on September 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the mass spectrometry rendered on April 28, 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 separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.    The provider submitted a claim for procedure codes 83789 (mass spectrometry) and 80307 (presumptive drug testing). Code 83789 is a column II code with a modifier indicator of 1 when billed with column I code 80307. Code 83789 was not billed with an appropriate modifier to allow for separate payment. The file does not support the -59 modifier as a separate and distinct procedure. Therefore, we decided that the Plan does not have to pay for the mass spectrometry rendered on April 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on June 18, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 31225 is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 31225 is maxillectomy; without orbital exenteration.  We find that CPT code 31225 is not supported in the medical record. Specifically, the operative report does not include documentation of a maillectomy without orbital exenteration, as an independent proedure. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on June 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.  You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not meet criteria.  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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you did not have any parental medications, complex wound care or nutrition given via a feeding tube. You received skilled care and improved; however, your functional improvement had plateaued by February 26, 2022 and you did not require any further inpatient skilled rehab services. Your function was at or near your prior level of function and you could be discharged to a lower level of care for further services.  As of February 26, 2022, you require custodial 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.