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

We decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions and
extraction provided on November 12, 2020, by an OON provider.
You asked the Plan to pay for the alveoloplasty and extraction. You say that the Plan advised that the treating
provider was in-network. The Plan denied your request. The Plan says these services were rendered by an OON
provider and are not covered because your healthcare plan does not have OON benefits. The Plan also says that
alveoloplasty in conjunction with extractions is not a covered benefit.
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, alveoloplasty in conjunction with
extractions is not among those covered under this benefit. The Plan contract also clearly states that enrollees
must pay 100% of the cost for OON dental services. The record shows that you contacted the Plan on
November 3, 2020, and were given the names of three different dentists and their office locations. The location
that you received these services at was not one of the office locations provided to you during the call.
Therefore, we decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions
and extraction provided on November 12, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 16, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you had all your labs done at his office. You say that you think this was coded wrong. The Plan denied your request. The Plan says the copayment 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 $35 copayment for each Medicare-covered specialist visit. You have been asked to pay $25.21, which is less than the standard $35 copayment for the office visit. The 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 copayment for the office visit provided on September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit.

You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing required information.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 99336 is not supported in the medical record. Specifically, the documentation does not include medical records to show if a physician's order was given, how the enrollee came to you (the rendering provider), or whether the services were necessary. Based on this information, we decided that Medicare rules for coverage of the rest home visit have not been met. Therefore, we decided that the Plan does not have to pay for the rest home visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5261).

You asked the Plan to pay for the hearing aids. You say that the hearing aids were medically necessary and should be covered. The Plan denied your request. The Plan says hearing services obtained out-of-network are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when obtained from network providers.

We looked at the file and the Plan's rules. The hearing aids were obtained out-of-network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5261).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee's condition warrants admission to an LTACH. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the care needed can safely be provided at a lower level of care.

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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) with suspension sleeve (L2397)
provided on September 1, 2020.
You asked the Plan to pay for a knee orthosis with suspension sleeve. You say that the enrollee is using these
medically necessary items with benefit. The Plan denied your request. The Plan says rules for payment have
not been met because there are no medical records showing that the prescribing physician ever saw the
enrollee.
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 a knee orthosis with suspension sleeve. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found that the documentation in the case file does not support that the requested
knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the
coverage criteria established by Medicare. There is insufficient documentation of an appropriate evaluation of
the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397
(sleeve) is not separately payable when the base item is not covered.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a knee orthosis have not been met. Furthermore, the requested suspension
sleeve is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not
have to pay for a knee orthosis (L1833) with suspension sleeve (L2397) provided on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating specialist on July 24, 2020.
You asked the Plan to waive the copayment for specialist services. You say that you did not see a doctor, you saw a nurse. The Plan denied your request. The Plan says the correct copayment has been applied.
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 physician/practitioner services/specialty physician. You have been asked to pay a $30 copayment for specialist services. A nurse practitioner is considered a specialist; therefore, the correct copayment has been applied. Specialist services fall within the physician/practitioner services/specialty physician 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 specialist services provided by a participating specialist on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on June 3, 2020 by an out of network (OON) provider. You asked the Plan to pay for subsequent nursing facility care. You say that you feel that the services should paid because the services are medically necessary. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered. 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 subsequent nursing facility care (99308) provided on June 3, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive eye exam (92204) provided on October 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the eye exam. You say that you are appealing the denial of the services. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 comprehensive eye exam (92204) provided on October 5, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429-QL) provided on October 27, 2020.
You asked the Plan to pay for ambulance services. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with the required code.
The Plan must follow Medicare rules. Medicare rules say that in the case where the beneficiary was pronounced dead after the ambulance is called but before the ambulance arrives at the scene, providers report the A0428 (BLS) HCPCS code, modifier QL, and modifier QM or QN. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these circumstances. Therefore, we decided that the Plan does not have to pay for ambulance services (A0429-QL) provided on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 16, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on August 3, 2020.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 nurse practitioner services provided on August 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on April 15, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that the enrollee had to take the ambulance due to the pandemic and should not be responsible for the charges. 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 $250 copayment for ambulance services. The enrollee has been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the ambulance services 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 ambulance services provided on April 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve SNF admission. You say that you would like reconsideration because you are weaker and having falls. The Plan denied your request. The Plan says you do not have skilled nursing or skilled therapy needs.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered screening testing services (CPT code (s): 88053 and 84443) provided to the enrollee on November 19, 2020, by a non-participating provider.
You asked the Plan to pay for non-covered screening testing services. You say that the claim should be paid. The Plan denied your request. The Plan says these services are not authorized because predictive screening testing is not a Medicare benefit. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, non-covered screening testing services, 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 non-covered screening testing services (CPT code (s): 88053 and 84443) provided to the enrollee on November 19, 2020, by a non-participating provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria have not been met.
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 40 one-way transportation 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 routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on June 17, 2020.
You asked the Plan to pay for psychotherapy. You say that the service was rendered according to the referring physician's order. You say that the hospital should not be penalized for providing the appropriate medically indicated treatment. The Plan denied your request. The Plan says services are available in-network.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis and suspension sleeve (L1833, L2397) provided on September 14, 2020.
You asked the Plan to pay for a knee orthosis and suspension sleeve. You say that the criteria for coverage were met. The Plan denied your request. The Plan says these items were not ordered by a physician that has treated the enrollee.
The Plan follows Medicare rules. Medicare rules say that for codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, knee instability must be documented by examination of the beneficiary and objective description of joint laxity. L coded additions to orthoses will be denied as not reasonable and necessary if either the base orthosis is not reasonable and necessary or the specific addition is not reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a knee orthosis and suspension sleeve. Our reviewer says that the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case. Our physician reviewer found
there is insufficient documentation of an evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis and suspension sleeve (L1833, L2397) provided on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued.

You asked the Plan to pay for the compression stockings. You say that the stockings were medically necessary. The Plan denied your request. The Plan says these items are not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued.