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

We decided that the Plan does not have to waive the copayment for the ambulance services provided on February 1, 2019 and May 18, 2019.You asked the Plan to waive the copayment forthe ambulance services. You say that the services were medically necessary.The Plandenied your request. The Plan says the enrollee was charged this cost sharing 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). The enrollee's contract with the Plan clearly says that they must pay a $275 copayment for each ambulance trip. The enrollee had two ambulance trips. The Plan charged $503.62, less than the copayment, for these services. This means that the enrollee has been asked to pay the correct amount based on their contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when you enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe ambulance services provided on February 1, 2019 and May 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe core buildup, including any pins when required, porcelain or ceramic crown, full mouth debridement, resin-based composite, comprehensive periodontal evaluation, and complete series of intraoral x-rays provided on August 5, 2019 and August 27, 2019.You asked the Plan to pay forthe core buildup, porcelain or ceramic crown, and full mouth debridement. You say that not having this procedure would have resulted in acute hospitalization.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 forthe core buildup, including any pins when required, porcelain or ceramic crown, full mouth debridement, resin-based composite, comprehensive periodontal evaluation, and complete series of intraoral x-rays provided on August 5, 2019 and August 27, 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 the services are necessary. The Plan denied your request. The Plan says the enrollee can receive the care required at the current facility they are in. Therefore, coverage criteria has not been met.
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 records show that the rate of improvement will likely need less than 25 days more of acute care. The enrollee does not require services at the LTACH that are not already being administered safely and covered at the current facility. Therefore, based on the provided documentation, this request for transfer to LTACH is considered not medically necessary. 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 professional services for allergen immunotherapy provided on September 20, 2019.You asked the Plan to waive the copayment forprofessional services for allergen immunotherapy. You say that you were quoted a lesser amount and disagree with the 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 $50 copayment for physician specialist services. You have been asked to pay the allowed amount of $9.61, which is less than the $50 copayment for professional services for allergen immunotherapy. Professional services for allergen immunotherapy 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 forprofessional services for allergen immunotherapy provided on September 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for OTC items provided on October 29, 2019.
You asked the Plan to reimburse you for the OTC items. The Plan denied your request. The Plan says that you were partially paid in the amount of $17.45 because you exhausted your monthly benefit and that was the balance you had at the moment of the request.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. However, the Plan offers an OTC items benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that at the time of your reimbursement request you had an unused balance of $17.45, which the Plan paid. You had exhausted your monthly benefit for any additional reimbursement. Therefore, we decided that the Plan does not have to reimburse you for OTC items provided on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a comprehensive hearing test provided on October 9, 2019.
You asked the Plan to waive the copayment for a comprehensive hearing test. You say that you went for your hearing exam. You say that you should not have a copayment for this. 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 hearing services/in-network/Medicare-covered visit. You have been asked to pay a $30 copayment for a comprehensive hearing test. Evidence was provided to show that comprehensive hearing test was provided. A comprehensive hearing test is considered a diagnostic test; therefore, the correct copayment has been applied. A comprehensive hearing test falls within the hearing services/in-network/Medicare-covered visit 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 comprehensive hearing test provided on October 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on June 29, 2018.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the claim for these tests 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 lab tests was not filed until August 27, 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 laboratory testing provided on June 29, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for monthly oxygen supplies (E0443) provided June 5, 2019 to September 5, 2019.You asked the Plan to waive the coinsurance for the oxygen. You say that the coinsurance should be waived The Plan denied your request. The Plan says the correct cost share 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 20% coinsurance for Durable Medical Equipment. You have been asked to pay a 20% coinsurance for the oxygen. The oxygen falls within the Durable Medical Equipment 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 coinsurance for monthly oxygen supplies (E0443) provided June 5, 2019 to September 5, 2019
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiation treatments provided from August 1, 2019 to August 12, 2019.
You asked the Plan to pay for the radiation treatments. You say that the claim has not been paid in full or under the terms of the contract for the services provided to the enrollee. The Plan denied your request. The Plan says the Medicare hospice benefits covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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. The record shows proof of hospice election from July 22, 2019 to September 14, 2019. Therefore, we decided that the Plan does not have to pay for the radiation treatments provided from August 1, 2019 to August 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the Enrollee on June 4, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 for the drug testing rendered to the Enrollee on June 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (SEWHO) (L3960) provided February 15, 2019.You asked the Plan to pay for the SEWHO. You say that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that the Medicare coverage criteria has been met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay forshoulder elbow wrist hand orthosis (SEWHO) (L3960) provided February 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by on October 2, 2019.
You asked the Plan to pay for the ambulance services to a physician office and the return trip. You say that the enrollee is bedridden and needed to get to the doctor. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to and from a doctor's office. Therefore, we decided that the Plan does not have to pay for the ambulance services provided by on October 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an excision (21931) provided on July 22, 2019.
You asked the Plan to pay for the excision. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 21931 was not the most appropriate service performed for the place of service 11.
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 21931 is not supported in the medical record. Specifically, per the 2019 Physician Fee Schedule, 21931 has a non-facility indicator of NA. This means that this procedure is rarely or never performed in a non-facility setting. Based on this information, we decided that Medicare rules for coverage of the excision have not been met. Therefore, we decided that the Plan does not have to pay for an excision (21931) provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on October 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that the services were provided to the enrollee in good faith. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says that the services were not urgent or emergent.
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 domiciliary visit provided on October 23, 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 copayment forthe eye exam provided on September 26, 2019.You asked the Plan to waive the copayment forthe eye exam. You say that you should not be responsible for the copayment because the person who performed the visual field test was not the person who usually performs the test. 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 $50 copayment for a medical eye exam. You have been asked to pay a $50 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The medical record shows a diagnosis of early dry stage age-related macular degeneration which makes the visit medical in nature.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 forthe eye exam provided on September 26, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthocentesis services provided on August 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the out-of-network arthocentesis services. The Plan denied your request. The Plan says the provider is a non-network provider with the enrollee's health plan. The Plan says that the enrollee self-directed and their primary care physician did not refer for the out-of-network services. The Plan says that there was no medical necessity for the services to be supplied out-of-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 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 arthocentesis services provided on August 5, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on February 13, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there are network provider who could have provided 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 has networkproviders available who can provide 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 forthe medical services provided to the enrollee by an out-of-network provider on February 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided to the enrollee on August 28, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service would be included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective payment systems are payment in full for all facility or hospital services, as defined in 42 CFR 409.10. CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements (as defined in 42 CFR 409.3). You can see this in 42 CFR 412.50 - "Furnishing of inpatient hospital services directly or under arrangements." Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided to the enrollee on August 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe joint survey, single view,2 or more joints provided on September 12, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe radiology services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says that the services were not urgent or emergent.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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe joint survey, single view, 2 or more joints provided on September 12, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora right knee orthosis (L1851-RT), a right suspension sleeve (L2397-RT), a left knee orthosis (L1851-LT), a left suspension sleeve (L2397-LT), a left ankle-foot orthosis (L1971-LT), and a lumbar-sacral orthosis (L0650) provided tothe enrollee on September 3, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the encounter appears to be a Telehealth service encounter however Telehealth guidelines have not been met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora right knee orthosis (L1851-RT), a right suspension sleeve (L2397-RT), a left knee orthosis (L1851-LT), a left suspension sleeve 
(L2397-LT), a left ankle-foot orthosis (L1971-LT), and a lumbar-sacral orthosis (L0650) provided to he enrollee on September 3, 2019.