Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transportation provided to the enrollee on August 12, 2019.
You asked the Plan to pay for non-emergency transportation. You say that this should be paid and extended because the enrollee needs the dialysis for the rest of their life. The Plan denied your request. The Plan says the enrollee exhausted their benefit
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of twenty-four (24) one-way routine trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of non-emergency transportation. Therefore, we decided that the Plan does not have to pay for non-emergency transportation provided to the enrollee on August 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 13, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because this was a follow-up visit. 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 $30 copayment for each specialist visit. You had a specialist visit on August 13, 2019. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 copayment for a specialist visit. A specialist 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 copayment for a specialist visit provided on August 13, 2019.
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 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. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on January 30, 2020. Her condition has stabilized as of February 7, 2020. She has no complex medical, nursing, or rehabilitation needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from further therapy, but it is not clear that she would be able to fully participate in, and benefit from, an intensive therapy program in an IRF. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on June 25, 2019 by out of network provider.You asked the Plan to pay forthe office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an out-of-network provider.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 has network providers available who can provide 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 forthe office visit provided on June 25, 2019 by the out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on July 19, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that you were never asked if you wanted to be transported by ambulance.The Plan denied your request. The Plan says that you are responsible for the copayment.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 $285 copayment for each Medicare-covered one-way trip via ground ambulance. You have been asked to pay a $285 copayment for the ambulance transport. the ambulance transport falls within the Medicare-covered one-way trip via ground ambulance 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 ambulance transport provided on July 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient behavioral health services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says there was no imminent danger to self or others, or functional impairment that requires an inpatient level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued services beyond February 7, 2020 was 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. The services were not reasonably expected to improve your condition, or for the purpose of diagnosis. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of February 7, 2020 forward as you were not shown to be a danger to herself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment. 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 behavioral health services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive several copayments charged for imaging services provided on September 18, 2019.
You asked the Plan to waive these copayments. You say that you do not believe these copayments are correct. The Plan denied your request. The Plan says these copayments were charged based on the services provided and the Plan contract agreement.
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 copayment for each separate imaging service provided. You have been asked to pay the correct amounts 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 several copayments charged for imaging services provided on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit you had on August 29, 2019.
You asked the Plan to pay for the visit. You say that you did not have a wellness visit on March 21, 2019. The
Plan denied your request. The Plan says this service is only allowed once per year.
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 an annual wellness visit once every 12 months.
Review of the file shows that you had an annual wellness visit on August 29, 2019. The records also show that
you had a covered annual wellness visit on March 21, 2019. This means that the requested visit exceeds the
benefit limit and is not covered. This means that you have been asked to pay the correct amount based on your
contract with the Plan. Therefore, we decided that the Plan does not have to pay for the annual wellness visit
you had on August 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to paymoreforthe resin-based composite -three surfaces, anterior, provided on June 19, 2019.You asked the Plan to pay more forthe resin-based composite. You say that you were advised 3 different times that this provider was in-network.The Plan denied your request. The Plan says your cost share responsibility is correct. The Plan also says that they confirmed that you were fully aware that this provider was out-of-network before the service was rendered.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 is only obligated to pay 80% of the allowed amount after the deductible has been applied.
ServiceBilled AmountAllowed AmountDeductible20% CoinsuranceDifference of Billed Amount & Allowed AmountMember LiabilityResin-based composite$306$108$100$1.60$198$299.60TOTAL:$299.60Therefore, we decided that the Plan does not have to pay more forthe resin-based composite -three surfaces, anterior, provided on June 19, 2019.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 1/28/20 for treatment of right femoral neck fracture following a fall. Prior level of function was independent without assistance. She underwent a total hip arthroplasty on 1/30/20. By 2/4/20 her pain was better controlled. She was weight-bearing as tolerated. On 2/5/20 she had no significant swelling and her incision to the right hip was clean and dry. Her pain was controlled and there were no acute events. By 2/6/20 in physical therapy (PT) she was minimal assist for transfers and bed mobility. She was ambulating 50 feet with front wheeled walker and toileting with moderate assistance. On 2/6/20 there were no acute events. The enrollee noted to live in a 2 story home without assist at home. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but the documentation does not reveal that the enrollee requires this therapy on an intensive rehabilitation facility therapy program level in an IRF.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee presented to the emergency department on 12/2/19 with complaint of 1 week of dyspnea and hoarseness and rapid enlargement of a neck mass. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different thanthose of short term acute care hospitals. In this case, ongoing care needs include respiratory support with tracheostomy care and ventilator management, tube feedings, scheduled chemotherapy, surveillance laboratory studies with indicated transfusions, wound care, and therapy services.The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical servicesidentified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met.Therefore, we decided that thePlan does not have to pre-approvelong term acute care hospital (LTACH) services
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on August 31, 2019.
You asked the Plan to waive the copay for the ambulance transport. You say that the plan should cover this because you were in the hospital due to an emergency. The Plan denied your request. The Plan says that the 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 $265 copay for each covered, one-way ambulance trip. You have been asked to pay less than a $265 copay for the ambulance transport. The ambulance transport falls within the one-way ambulance trip 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 copay for the ambulance transport provided on August 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, and each additional intraoral periapical x-ray provided on September 17, 2019.
You asked the Plan to pay for the comprehensive oral evaluation and intraoral periapical x-rays. You say that you were told that you were still in-network with the enrollee's plan. The Plan denied your request. The Plan says the enrollee does not have coverage with an out-of-network provider. The Plan also says that they confirmed that the representative did not provide the information that you were a participating provider.
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 when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, and each additional intraoral periapical x-ray provided on September 17, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 9, 2019.
You asked the Plan to pay for the laboratory services. You say that this provider is the only service provider for this cell-free circulating tumor DNA test. 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 enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical insertion of the Superion Interspinous stabilization device (22869).
You asked the Plan to pre-approve these services. You say that the services are medically necessary as the enrollee has lumbar spinal stenosis. The Plan denied your request. The Plan says overall, there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of decompression. In addition, there appears to be concern that the devices are not as effective as surgical decompression and lead to higher rates of reoperation.
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 requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that interspinous decompression devices are not recommended over decompression surgery which is the gold standard for treating lumbar spinal stenosis. In this case, the member does not meet criteria for the requested spinal spacer as she does not have documented findings of spinal stenosis by reported imaging. There is also no evidence of a failure of recommended conservative treatment such as the repeat epidural steroid injections being planned. Additionally, there is no evidence of at least moderately impaired physical function either by history or by assessment. 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 the surgical insertion of the Superion Interspinous stabilization device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99203) to be provided by the out of network
provider.
You asked the Plan to pre-approve the office visit. You say that you feel you can get the best treatment with
this provider. The Plan denied your request. The Plan says there are in-network providers that are able to
provide this care. Therefore, coverage criteria has not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve 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 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
an office visit (99203) to be provided by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the complete series of x-rays (D0210), the comprehensive periodontal evaluation (D0180), and full mouth debridement (D4355) provided on October 2, 2019 by the out of network dentist.
You asked the Plan to pay the full amount for the dental services. You say that the bill you received does not agree with your benefit booklet. The Plan denied your request. The Plan says the dentist in this case is out of network. The Plan also says that you are responsible for any amount over the allowed amount when you receive dental services out of network.
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 and the services are listed as covered, you are responsible for any amount over the allowed amount when you receive the dental services out of network.
Date of Service
Service/CPT
Billed Amount
Allowed Amount
Deductible Applied
Plan Paid
You Pay
10/2/2019
D0210
$167
$70
$0
$70
$97
10/2/2019
D0180
$110
$28
$0
$28
$82
10/2/2019
D4355
$182
$64
$64
$0
$182
TOTAL:
$361
Therefore, we decided that the Plan does not have to pay the full amount for the complete series of x-rays (D0210), the comprehensive periodontal evaluation (D0180), and full mouth debridement (D4355) provided on October 2, 2019 by the out of network dentist.