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

We decided that the Plan does not have to pay for the drug testing services provided on May 22, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on May 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 14,
2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
services from non-participating providers are not covered unless they are prior authorized by the Plan.
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 subsequent nursing facility care provided on November 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental fillings (D2332) provided January 22, 2020.
You asked the Plan to pay for the fillings. You say that the fillings should be covered. The Plan denied your request. The Plan says the annual maximum for dental services 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. The Plan covers the fillings when the services are medically necessary and reasonable. We looked at the plan contract, the file, and Medicare rules. The record shows you already met the $500 annual maximum for covered dental services by the date of service at issue. Based on this information, we decided that the Plan's rules for coverage of the fillings have not been met. Therefore, we decided that the Plan does not have to pay for dental fillings (D2332) provided January 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 17111 provided on October 7, 2019.
You asked the Plan to pay for CPT code 17111. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 17111.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 17111 is Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions. We find that CPT code 17111 is not supported in the medical record. Specifically, the file does not show that 15 or more lesions were treated. Based on this information, we decided that Medicare rules for coverage of CPT code 17111 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 17111 provided on October 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral exam (D0150) fluoride application (D1206) and resin based fillings (D2391x2)
You asked the Plan to pay for the dental services. You say that you are on disability and is unable to pay the extra costs and is requesting help with this bill. The Plan denied your request. The Plan says these services are not covered.
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 only covers 1 oral exam a year. The plan approved 1 oral exam, therefore this service is not covered. The plan only covers for amalgam fillings. Therefore, the 2 resin fillings are not covered. The Fluoride application is not listed as covered under the description of benefit. 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 oral exam (D0150) fluoride application (D1206) and resin based fillings (D2391x2)
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Observation Hospital Care provided January 13 to January 14, 2020. 
 
You asked the Plan to waive the copayment for the observation care. You say that you stayed overnight so the inpatient copayment should apply. The Plan denied your request. The Plan says the record shows you were not admitted as an inpatient. 
 
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 $350 copayment for Outpatient Observation Care.  
 
You have been asked to pay a $350 copayment for the observation 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 copayment for Observation Hospital Care provided January 13 to January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray and walking boot provided on January 8, 2020 by an out of network provider.
You asked the Plan to pay for the x-ray and walking boot. You say that the enrollee was evaluated in your office for post-operative care. The Plan denied your request. The Plan says the out-of-network 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 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 x-ray and walking boot provided on January 8, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Intraoral and Bitewing Dental X-rays (D0220, D0230, D0274) provided February 10, 2020. You asked the Plan to pay for the X-rays. You say that the service should be covered because the plan covers dental x-rays.The Plan denied your request. The Plan says coverage is only provided for a complete series once a year, billed using code D0210. 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 Intraoral and Bitewing Dental X-rays (D0220, D0230, D0274) provided February 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided December 21, 2019 through December 24, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services The Plan denied your request. The Plan says the SNF benefit has been exhausted.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from July 25, 2019 to December 20, 2019. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided December 21, 2019 through December 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you need this level of care. The Plan denied your request. The Plan says that the skilled nursing level of care exceeds your medical needs.
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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 22, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 physician's services provided on October 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional ambulance mileage provided during transport on December 20, 2019.
You asked the Plan to pay for the additional ambulance mileage. You say that you did not realize there would be an additional charge for not going to the nearest hospital. The Plan denied your request. The Plan says you transported to your preferred hospital not the closest appropriate facility.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file and Medicare rules. The excess mileage charge to the preferred facility is non-covered. Based on this information, we decided that Medicare rules for coverage of the additional ambulance mileage have not been met. Therefore, we decided that the Plan does not have to pay for the additional ambulance mileage provided during transport on December 20, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for a colonoscopy provided on December 31, 2019. 
 
You asked the Plan to waive the deductible and copayment for a colonoscopy. You say that you had a colonoscopy due to bowel changes and disagree with the additional $150 charge. 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. Your contract with the Plan says that there is a $250 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Your contract with the Plan also clearly says that after the $250 deductible has been met, you must pay a $150 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
You received a colonoscopy on December 31, 2019 due to bowel changes. The record shows that you had paid $0 toward the $250 deductible prior to receiving the services. Therefore, you are responsible to pay the $250 deductible. Now that the deductible has been met, you are also responsible to pay the $150 copayment. The total amount you owe is: $400.  
 
The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time a colonoscopy was received on December 31, 2019. Therefore, we decided that the Plan does not have to waive the deductible and copayment for a colonoscopy provided on December 31, 2019.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee required stand-by assistance with grooming. The enrollee required minimal assistance with upper body dressing and standing up. The enrollee required contact guard assistance to sit down. The enrollee is currently undergoing treatment at a LTACH for obesity hypoventilation syndrome. The enrollee is not intubated/ventilated. The enrollee is participating in rehabilitative services. There is no evidence that the enrollee requires the level of service provided at a LTACH. The enrollee's care needs can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation services provided from
January 26, 2020 to January 27, 2020.
You asked the Plan to waive the copayment for the observation services. You say that you were told the
copayment would be waived if readmitted within 60 days of the first visit. You say you were not told this was
different for inpatient versus outpatient. The Plan denied your request. The Plan says you have been charged
the correct cost sharing 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 $275
copayment per visit for Medicare-covered services.
You have been asked to pay a $275 copayment for the observation services. The observation services fall
within the "Outpatient Hospital Observation" 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 observation services provided from January 26, 2020 to January 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from August 1, 2019 to August 31, 2019.
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. The file shows that the claim was billed with an invalid type of bill for the services provided. Therefore, we decided that the Plan does not have to pay for the medical services provided from August 1, 2019 to August 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on November 21, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room through the entire procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on November 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eszopiclone.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 pre-approve Eszopiclone.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 pre-approve Oxycodone.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prednisone.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not a covered benefit.
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 pre-approve prednisone.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames and lenses provided on February 23, 2020.
You asked the Plan to pay for the frames and lenses. You say that you would like reconsideration because the
network optometrist did not have frames that were affordable. The Plan denied your request. The Plan says in
order to be eligible for the $100 allowance, the provider must participate with EyeMed.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when you use an EyeMed select provider for routine coverage.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the frames and lenses have not been met. Specifically, in order to be eligible for the $100 eyewear
allowance, you must receive services from an EyeMed provider. The record indicates that these services were not rendered by an EyeMed provider. Therefore, we decided that the Plan does not have to pay for frames and
lenses provided on February 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for home health care with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are multiple available home health care providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. 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 a referral for home health care with an out-of-network provider.