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

We decided that the Plan does not have to pay for the acute inpatient hospital care provided June 11, 2021 to June 12, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that you are upset that the authorizations were denied. You had a stroke and heart surgery, and you feel that the provider did not send enough information for the authorization to be approved. The Plan denied your request. The Plan says this request is not medically necessary as the records do not show that you meet the criteria for inpatient admission.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the hospital with fatigue and was found to have symptomatic bradycardia requiring permanent cardiac pacer which was placed without complication or issue. She was sent home for outpatient follow-up. She was hemodynamically stable and was not expected to require inpatient hospital services that would likely cross 2 midnights due to the low complexity and severity of the case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided June 11, 2021 to June 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the methylprednisolone injection provided
on April 20, 2021.
You asked the Plan to waive the coinsurance for the methylprednisolone injection. You say that your prior plan
did not have any costs and you have never had to pay for an injection before. The Plan denied your request.
The Plan says the coinsurance 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 20%
coinsurance for chemotherapy drugs and all other Part B drugs at a PCP's office, specialist's office and
outpatient hospital setting.
You have been asked to pay $2.30, which is 20% of the allowed amount for the methylprednisolone injection.
The allowed amount is $11.49 (20% x $11.49 = $2.30). The methylprednisolone injection falls within the
"Medicare Part B prescription drugs" 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
the methylprednisolone injection provided on April 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the removal of spinal neurostimulator electrode plate/paddles provided on March 18, 2021.
You asked the Plan to waive the copayment for these services. You say that these services were medically necessary. The Plan denied your request. The Plan says that your claim processed 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 $290 copayment for each Medicare-covered outpatient hospital facility visit. You have been asked to pay a $290 copayment for these services. These services fall within the each Medicare-covered outpatient hospital facility visit 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 removal of spinal neurostimulator electrode plate/paddles provided on March 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression device (E0675) segmental gradient pressure pneumatic appliance (E0673) provided March 17, 2021.
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you would like this claim to be reconsidered for payment as a medically necessary preventative measure. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. In this case, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device and appliance have not been met. Therefore, we decided that the Plan does not have to pay for pneumatic compression device (E0675) segmental gradient pressure pneumatic appliance (E0673) provided March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the endodontic therapy (D3330) provided on January
14, 2021, by an OON provider.
You asked the Plan to pay more for the endodontic therapy. You say that you were not aware that your
insurance covered this service, and when you contacted the Plan about it you were told that this service would
be covered at 50%. The Plan denied your request. The Plan says the total $971.50 amount applied correctly as
your liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be
waived.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a 50%
coinsurance for the endodontic therapy, plus the difference between the billed amount and allowed amount
because the service was received OON. Therefore, we decided that the Plan does not have to pay more for the
endodontic therapy (D3330) provided on January 14, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation - per quadrant (D4921), drugs or
medicaments dispensed in the office for home use (D9630) and localized delivery of antimicrobial agents via a
controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided February 4, 2021.
You asked the Plan to pay for the gingival irrigation, drugs for home use and localized delivery of
antimicrobial agents. You say that these services are medically necessary to prevent infection in your gums.
The Plan denied your request. The Plan says these services are 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 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
gingival irrigation - per quadrant (D4921), drugs or medicaments dispensed in the office for home use (D9630)
and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue,
per tooth (D4381) provided February 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Colectomy represented by code 44156 provided on July 
3, 2020. 
 
You asked the Plan to pay for code 44156. You say that the medical records support the billing of code 44156. 
The Plan denied your request. The Plan says the medical records do not support the billing of code 44156. 
 
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 44156 is Colectomy, total, abdominal, with proctectomy; 
with continent ileostomy. We asked our coder 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 code 44156. Our reviewer says that the medical records do 
not support the billing of code 44156. Our reviewer found the enrollee underwent a procedure on July 3, 2020.  
The operative report indicates that the enrollee underwent total abdominal proctocolectomy. The operative 
report does not indicate that a continent ileostomy was created. The elements of the coverage criteria are not 
satisfied.  The requested service cannot be recommended. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 44156 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Colectomy represented by code 44156 provided on July 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for TENS device, four or more leads, for multiple nerve
stimulation (CPT code(s): E0730 and A4556) provided to the enrollee on June 19, 2020, by an out-of-network
provider.
You asked the Plan to pay for the services. You say that these treatments were performed in good faith. The
Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. There is no evidence of the enrollee
being in an approved clinical study.
Therefore, we decided that the Plan does not have to pay for TENS device, four or more leads, for multiple
nerve stimulation (CPT code(s): E0730 and A4556) provided to the enrollee on June 19, 2020, by an out-ofnetwork
provider.
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 January 2, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the
ambulance personnel advised that they wanted you to go to the hospital, but you declined out of fear of
contracting the Coronavirus. The Plan denied your request. The Plan says ambulance transportation is only
covered when you are actually transported by ambulance. The Plan also says that this service is not covered
under your plan because you were not transported by this ambulance.
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 January 2, 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 January 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on March 14, 2021.
You asked the Plan to waive the copayment for an MRI. You say that you feel that the test should be considered preventative. 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 $325 copayment for diagnostic radiology other than ultrasounds.
The medical records show that you received an MRI on March 14, 2021. There is no indication that preventative services were received. Therefore, you are responsible to pay the $325 copayment. You have been asked to pay a $325 copayment for an MRI. An MRI 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 MRI provided on March 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee orthosis (L1851).
You asked the Plan to pre-approve the orthosis. You say that this device will help lesson the pain of walking and balance. It is better than getting an operation on the leg, or maybe even amputation of part of the leg. The Plan denied your request. The Plan says under Medicare guidelines you do not meet the criteria and the request is 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 the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the records indicates that the enrollee has arthritis of the knee. The records do not indicate that the enrollee has had recent surgery or injury. Physical examination indicates that the knee is stable. The elements of the coverage criteria are not satisfied, and the requested service is not recommended. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the knee orthosis (L1851).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction (D7210).
You asked the Plan to pre-approve the dental service. You say that you do not understand why the wisdom tooth needs to be impacted for it to be removed and covered. You say that you are on a limited fixed income. You also say that you are not able to afford this service without assistance from your insurance. The Plan denied your request. The Plan says routine dental services are not covered by Medicare or the Plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve an extraction (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas services rendered from January 28, 2021, to
February 9, 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.
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 the Sanexas services rendered from January 28, 2021, to February 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the implantable neurostimulator rendered on May 13, 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.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. We looked at the file and Medicare rules. The file shows that the services were performed in the office setting and not in the home. Therefore, we decided that the Plan does not have to pay for the implantable neurostimulator rendered on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 2,
2021.
You asked the Plan to waive the copayment for a specialist visit. You say that the enrollee suffered a stroke
after having the coronavirus so you request that the charges be waived. The Plan denied your request. The Plan
says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $40 copayment for specialist visits.
The enrollee has been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits benefit category. This means that the enrollee
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not
have to waive the copayment for a specialist visit provided on March 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) physical therapy visits (97110, 97014, 97022, 97035, 97112, 97116, 97140, 97161, 97162, 97164) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve physical therapy visits. You say that you are a retired nurse, and you chose this provider based on ratings and the care you need. The Plan denied your request. The Plan says there are in-network providers available for these services.
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. The records provided for review do not show that the services at issue are urgent or emergent. 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 six (6) physical therapy visits (97110, 97014, 97022, 97035, 97112, 97116, 97140, 97161, 97162, 97164) to be provided by an out-of-network (OON) provider.
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of 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 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: Favorable

We decided that the Plan has to pay for three additional fillings (D2330) provided on April 9, 2021, for a total of five fillings.

You asked the Plan to pay for the fillings. You say that it is unfair that the contract states you are covered for two visits every year for restorations, but the Plan really means two services. You had five fillings done and are now being charged for three of them. The Plan denied your request. The Plan says that you are covered for two services per year, and the Plan has covered two of the fillings. You are responsible for the cost of the remaining three.

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. The Plan covers restorative services for up to two visits per year. 

We looked at the file, the Plan's contract and Medicare rules. The contract clearly states that you are covered for restorative services for up to two visits a year. The contract does not state that you are covered for only two services, two procedures, or two restorations per year, but two visits. All five fillings were performed within a single visit. Based on this information, we decided that the Plan's rules for coverage of the fillings have been met. Therefore, we decided that the Plan has to pay for three additional fillings (D2330) provided on April 9, 2021, for a total of five fillings.

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.