Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 1, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 had network providers available who could have provided the services at issue in this appeal. 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 the services provided by an out-of-network provider on February 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the hydrocortisone, 10 mg tablet, and the ropinirole, 1 mg tablet, provided in an outpatient setting on February 16, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you received an approval for a Repatha sureclick 140 mg/ml injection pen on January 25, 2021.
You also say that you do not understand why this was not paid. The Plan denied your request. The Plan says the drug you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the hydrocortisone, 10 mg tablet, and the ropinirole, 1 mg tablet, provided in an outpatient setting on February 16, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for exercise classes (S9451) purchased on January 3, 2020, in the amount of $18.

You asked the Plan to pay for the exercise classes. You say that the center did not provide receipts, and no one was available to verify your information after the center closed due to the pandemic. You are surprised that these services are denied, as they have been covered in the past. The Plan denied your request. The Plan says proof of payment was not submitted with this request. The Plan was only able to verify a payment in the amount of $70 for health club services out of the total requested reimbursement amount of $88. The Plan has provided reimbursement for the $70 amount but is unable to pay the remaining $18 without proof of payment.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan provides reimbursement for gym benefits only when the Wellness Allowance reimbursement form and proof of payment are submitted.

The Plan's rules for coverage of gym benefits have not been met because your request did not include proof of payment. Therefore, we decided that the Plan does not have to pay for exercise classes (S9451) purchased on January 3, 2020, in the amount of $18.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nail debridement services provided by a participating provider on February 8, 2021.
You asked the Plan to waive the copayment for an outpatient surgery. You say that this should not be considered an outpatient surgery. 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 $200 copayment for outpatient surgery/in-network. You have been asked to pay a $200 copayment for an outpatient surgery. Nail debridement services are considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls within the outpatient surgery/in-network 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 nail debridement services provided by a participating hospital on February 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for inpatient hospital care provided on December 23 to December 31, 2020.

You asked the Plan to waive the co-payment for inpatient hospital care. You say that the inpatient hospital care was due to an accident during surgery and you do not feel you should have to pay for a stay caused by the provider. The Plan denied your request. The Plan says the correct co-payment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 co-payment per admission for each medically necessary inpatient stay.

You have been asked to pay a $325 co-payment for inpatient hospital care. 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 co-payment for inpatient hospital care provided on December 23 to December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventative procedure, by report (D1999) provided December 17, 2020.
You asked the Plan to pay for the unspecified preventative procedure. You say that the website is not user-friendly, so it was difficult to find a network provider. The Plan denied your request. The Plan says the services from this date of service have been reprocessed however the unspecified preventative procedure is not covered under your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers 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 unspecified preventative procedure, by report (D1999) provided December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 1, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99215) provided on January 25, 2021, by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like reconsideration of the denied claim. 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit (99215) provided on January 25, 2021, 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 initial periapical x-ray (D0220) and 6 additional periapical x-rays (D0230) provided on January 6, 2021.
You asked the Plan to pay for the dental services. You say that you were advised you would only have to pay $50 for the x-rays. You say that you paid them. You say that now you received a bill for $140. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan also says that the frequency limit has been exceeded.
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 periapical x-ray is listed as a covered, the frequency limit has been exceeded. The record shows that the Plan paid for 1 periapical x-ray that you received on the date of service in this case. Additionally, the record shows that the provider applied the $50 to the $140 total, making your responsibility $90. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and 6 additional periapical x-rays (D0230) provided on January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 lab work provided on December 9, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips.
You asked the Plan to provide additional routine transportation. You say that this enrollee has multiple medical concerns which require ongoing therapy and follow-ups. They require additional transportation as they do not drive. The Plan denied your request. The Plan says the plan can cover up to 50 one-way trips to plan-approved locations. Additional trips are not covered.
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 50 trips per year.
We looked at your request, the records in the case file, and the rules. The Plan offers a maximum of 50 one-way routine transportation trips per year. Based on this information, we decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 5, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lesion destruction surgery provided on November 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for surgical service. You say that you have been going to the same provider for years and they accept your insurance card without question. 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 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 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 lesion destruction surgery provided on November 4, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99153) provided on February 17, 2021.

You asked the Plan to pay for sedation services. You say that this was billed with the correct place of service.
The Plan denied your request. The Plan says this is not separately payable in an outpatient hospital.

The Plan must follow Medicare rules. Medicare rules say that Services with status indicator N are paid under
the OPPS, but their payment is packaged into payment for a separately paid service.

We looked at the file and Medicare rules. The service at issue has a status code of N, meaning payment for this
service is packaged into payment for other services. Based on this information, we decided that Medicare rules
for coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay
for sedation services (99153) provided on February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D1110, D0330, D0120) received March 8, 2021 from the out-of-network provider.

You asked the Plan to pay for the dental services (D1110, D0330, D0120). You say that you did not want to switch to a different dental office because he does not know their cleaning procedures related to the pandemic. The Plan denied your request. The Plan says your dental services must be performed by a network 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 under this benefit. Your dental services must be performed by a Plan-participating Medicare Dental network provider. The provider in this case is not part of the Plan's dental network. Therefore, we decided that the Plan does not have to pay for the dental services (D1110, D0330, D0120) received March 8, 2021 from the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received February 3, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that the Plan should pay for this procedure. The Plan denied your request. The Plan says you have exhausted the frequency benefit limitation for this procedure.
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 the comprehensive oral evaluation once every three calendar years. We looked at the file, and Medicare rules. The Plan has submitted evidence that you last received, and the Plan covered, a comprehensive oral evaluation on March 13, 2019. The Plan limits coverage of this procedure to once every three years. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received February 3, 2021.
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 want to walk again and need more intensive therapy. The Plan denied your request. The Plan says the clinical notes do not support the medical need of care in an IRF.
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 there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health aide.

You asked the Plan to pre-approve the aide. You say that this is medically necessary, as your family is only able to help out 1-2 days per week. The Plan denied your request. The Plan says the services are not medically reasonable or necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 aide. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the documentation does not support that you require skilled nursing or rehab services to provide treatment that is medically necessary. The services are not needed to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.

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 aide have not been met. Therefore, we decided that the Plan does not have to pre-approve a home health aide.
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 these services are medically necessary. The Plan denied your request. The Plan says that tYOU may be equally well served at an alternative level of care.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a tibial plateau fracture and for a clavicle fracture after a fall. Your medical conditions are stable. There are no
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require
physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There is not a reasonable expectation
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF
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.