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

We decided that the Plan does not have to pay for the skilled nursing services provided from July 26, 2019 to August 3, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require or receive continued daily therapy and/or daily skilled nursing services during this time.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from July 26, 2019 to August 3, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services provided from August 16, 2019 to August 29, 2019
You asked the Plan to pay for home health care services. You say that you need these services. The Plan denied your request. The Plan says services from providers that do not participate in Medicare are not covered.
The Plan must follow Medicare rules. Medicare rules say that home health services are covered only when the home health agency that is providing the services to the beneficiary has in effect a valid agreement to participate in the Medicare program We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care services have not been met. The provider you received these services from does not participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for home health care services provided from August 16, 2019 to August 29, 2019
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services (73130, 99283) provided October 24, 2019
You asked the Plan to waive the copayment for the Emergency Room services. You say that the hospital is at fault for the charges and the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing was 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 $75 copayment for Emergency Care. You have been asked to pay a $75 copayment for the Emergency Room services. The Emergency Room services fall within the Emergency Care 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 Emergency Room Services (73130, 99283) provided October 24, 2019
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy provided from September
11, 2019 through October 18, 2019.
You asked the Plan to waive the copayments for physical therapy. You submitted your bill for review. The Plan
denied your request. The Plan says the copayments 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 $40
copayment for in-network, Medicare-covered physical therapy.
You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is
$440 ($40/visit x 11 visits = $440). Physical therapy falls 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 copayments for physical therapy provided from September 11,
2019 through October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a nursing facility visit provided on May 2, 2018.
You asked the Plan to pay for physician visit. You say that you attempted to submit the claim within the timely filing limit, but it was rejected. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not submitted within the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for physician visit was not filed until July 15, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a nursing facility visit provided on May 2, 2018.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing provided on October 1, 2019.
You asked the Plan to pay for drug test. You say that this testing was deemed medically necessary by the ordering physician, and it was not the responsibility of your laboratory to create a treatment plan or have any contact with the enrollee. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test exceeds the maximum covered frequency of 18 tests per year.
The Plan must follow Medicare rules. Medicare rules say that the frequency of presumptive urinary drug testing may be limited to 156 times per year for enrollees with 0 to 90 consecutive days of abstinence or 36 times per year for enrollees with more than 90 consecutive days of abstinence. We looked at the file and Medicare rules. Our review of the rules did not reveal a limitation of 18 tests per year for these services, as cited by the Plan. The Plan has not shown that this test exceeded the frequency limitation for presumptive urinary drug testing as cited above in the LCD. Based on this information, we decided that Medicare rules for coverage of drug test have been met. Therefore, we decided that the Plan has to pay for drug testing provided on October 1, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services
You asked the Plan to waive the copayment for the Emergency Room services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing was 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 $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the Emergency Room services. The Emergency Room services fall within the Emergency Care 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 Emergency Room Services
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on October 26, 2019.
You asked the Plan to pay for the ambulance service and ground mileage. You say that emergent transports are not covered under hospice. You also say that the enrollee went for a higher level of care. 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 ambulance service and ground mileage provided on October 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for actinotherapy provided on October 30, 2019.
You asked the Plan to pay for actinotherapy. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 actinotherapy provided on October 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services rendered to the enrollee on July 1, 2019 to July 30, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that home health claims require distinct 5-position, alphanumeric home health HIPPS codes.We looked at the file and Medicare rules. The claims were not billed with the required HIPPS codes. 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 forthe home health services rendered to the enrollee on July 1, 2019 to July 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic parenteral drugs provided on October 10,
2019.
You asked the Plan to pay for the therapeutic parenteral drugs. You say that this was medical and should be
paid by your insurance. You also say that you are on a fixed income. The Plan denied your request. The Plan
says this service 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, 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
therapeutic parenteral drugs provided on October 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the problem focused limited oral evaluation
(D0140) provided on December 9, 2019.
You asked the Plan to waive the copayment for the problem focused limited oral evaluation. You say that you
feel the dentist never did an evaluation of your mouth. You also say that the dentist only looked at your partial
and sent you to the desk to get an estimate. The Plan denied your request. The Plan says you are responsible for
a $25 office visit charge if this service is performed by a general dentist. The Plan also says that this copayment
was applied appropriately.
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 Evidence of Coverage clearly
states that there is a $25 copayment for preventive dental visits. Therefore, we decided that the Plan does not
have to waive the copayment for the problem focused limited oral evaluation (D0140) provided on December
9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy and core buildup, including any pins
when required, provided on June 27, 2019.
You asked the Plan to pay for the endodontic therapy and core buildup. You say that a Plan representative told
you that this provider was in-network. You also say that you are on a fixed income and this has been a financial
burden. The Plan denied your request. The Plan says these services are not covered 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
endodontic therapy and core buildup, including any pins when required, provided on June 27, 2019.
Your complaint about being misled by the Plan is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fordialysis provided on August31, 2019 by an out of network (OON) provider.You asked the Plan to pay fordialysis. You say that these services were medically necessary.The Plan denied your request. The Plan says there are in-network providers available for these services. The Plan says that no prior authorization was obtained.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 fordialysis provided on August 31, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an urgent care visit and specialist services provided on October 25, 2019. You asked the Plan to waive the copayments for an urgent care visit and specialist services. You say that you disagree with being charged two copayments. 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 $25 copayment for urgently needed services provided at an urgent care center. Your contract with the Plan also clearly says that you must pay a $30 copayment for specialist services. You had an urgent care visit on October 25, 2019. Therefore, you are responsible to pay the $25 copayment. You received specialist services on October 25, 2019. Therefore, you are responsible to pay the $30 copayment. The total amount you owe is: $55. You have been asked to pay the total copayment amount of $55 for an urgent care visit and specialist services. An urgent care visit falls within the urgently needed services benefit category. Specialist services fall 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 copayments for an urgent care visit and specialist services provided on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a sacroiliac joint injection provided on October 8, 2019.
You asked the Plan to waive the copayment for a sacroiliac joint injection. You say that you disagree with the surgery charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $320 copayment per visit for outpatient surgery services provided in an outpatient hospital facility. You have been asked to pay $150, which is less than the $320 copayment for a sacroiliac joint injection. A sacroiliac joint injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center 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 sacroiliac joint injection provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for chiropractic spinal manipulation (98940) and pay for electrical stimulation (97032) and mechanical traction therapy (97012) provided from August 2, 2019 to September 6, 2019.
You asked the Plan to waive the deductible for chiropractic spinal manipulation and pay for electrical stimulation and mechanical traction therapy. You say that these services were previously covered. The Plan denied your request. The Plan says these services processed correctly.
The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $300 deductible for all services excluding preventative services, emergency room visits, emergency ambulance, urgent care, and applicable riders. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for all services excluding preventative services, emergency room visits, emergency ambulance, urgent care, and applicable riders. This cost sharing is a contractual obligation that had not been met at the time chiropractic spinal manipulation was received on August 2, 2019 to September 6, 2019. The other services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to waive the deductible for chiropractic spinal manipulation (98940) and pay for electrical stimulation (97032) and mechanical traction therapy (97012) provided from August 2, 2019 to September 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 3, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that this should be covered because it was too dangerous for your wife to drive you. The Plan denied your request. The Plan says that the cost share was applied in accordance with your Evidence of Coverage.
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 $200 copayment for each one-way Medicare-covered ambulance transport. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ambulance transport 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 October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 14, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for office visit. You say that you are appealing with records. The Plan denied your
request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network
with the Plan and prior authorization was not obtained.
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 for the medical services provided on October 14, 2019
by an out of network (OON) provider.