Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued home health aide services for the enrollee.You asked the Plan to pre-approvethe services. You say that the enrollee is in dire need for continued home health care, as there is a high risk for falls.The Plandenied your request. The Plan says care are not met for continued home health nursing visits.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the records do not show that this enrollee requires skilled nursing services to effectively provide treatment, care, and/or services in order to improve the patient's condition, to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. There are no complex wounds, new enteral feedings, IV antibiotics or other SN level need. As the enrollee does not require skilled nursing or therapy services the services do not meet the definition of home health aide services as per Section 50.2 and the home health aide services are not reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued home healthaide services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 2, 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 April 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for myelography via lumbar injections provided from November 19, 2019 to January 24, 2020.
You asked the Plan to waive the copayments for myelography via lumbar injections. You say that you disagree with the outpatient hospital facility charges because you only received injections. 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 $250 copayment for surgery services provided in an outpatient hospital facility. You received myelography via lumbar injections from November 19, 2019 to January 24, 2020 for a total of 3 services. Myelography via lumbar injections is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $250 copayment per each visit. The total amount you owe is: $250 (copayment) x 3 (services) = $750. You have been asked to pay the total copayment amount of $750 for myelography via lumbar injections. Myelography via lumbar injections falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 myelography via lumbar injections provided from November 19, 2019 to January 24, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on February 12, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you do not feel you should be responsible for the copayment. 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 $90 copayment per Medicare-covered emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 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 the emergency room visit provided on February 12, 2020.
Your complaint about being misdiagnosed 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 waive the copayment for the office visit provided on February 20, 2020.
You asked the Plan to waive the copayment for the office visit. You say that the doctor didn't see you. You say that the Plan shouldn't have to pay them. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment per specialist visit. You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was for osteoarthritis of the knee. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe mandibular partial denture (D5214) provided on January 7, 2020.You asked the Plan to pay forthe mandibular partial denture. You say that in 2019 you began dental treatment requiring the removal of five lower front teeth, but your gums needed to heal before you obtained a permanent partial plate. You also say that you were not notified by the Plan prior to the service in 2020 that dentures were no longer covered.The Plan denied your request.The Plan says this service is not a covered benefit under your dental plan.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 inthis 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. The Plan confirmed that you were mailed a copy of the 2020 Annual Notice of Change on September 17, 2020, which clearly stated that the dental coverage for 2020 had been changed.Therefore, we decided that the Plan does not have to pay forthe mandibular partial denture (D5214) provided on January 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on November 8, 2016.
You asked the Plan to waive the copayment for the CT scan. You say that you were not advised by the hospital that you would have an additional copayment. You say you feel you are not responsible for the bill. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment for advanced radiology services (such as MRI, PET, CT and nuclear medicine). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $255 copayment for the CT scan.
The enrollee has been asked to pay a $203.22 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows you received a CT scan of the abdomen and pelvis.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the CT scan provided on November 8, 2016.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided on January 3, 2020.You asked the Plan to pay forthe dental services. You say that you did not choose the dentist you saw that day.The Plandenied your request. The Plan says that these procedures are not a covered benefit when rendered by a dentist who does not participate in the Medicare Advantage network.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 states that dental services are not a covered benefit when rendered by a dentist who does not participate in the Medicare Advantage network. We looked at the file and Medicare rules. The dental services were not rendered by a dentist who participates in the Medicare Advantage network. Based on this information, we decided that the Plan's rules for coverage of the dental services have not beenmet.Therefore, we decided that the Plan does not have to pay forthe dental services provided on January 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from January 31, 2020 to February 7, 2020.
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 the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from January 31, 2020 to February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatry services provided on April 25, 2019 to July 3,
2019 by an out of network (OON) provider.
You asked the Plan to pay for psychiatry services. You say that these services were requested from the
member's living facility. You say that you would like these services reimbursed. The Plan denied your request.
The Plan says the member's long-term care facility is out-of-network. 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 for psychiatry services provided on April 25, 2019 to
July 3, 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 for the urgent care visit provided on December 5, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were overcharged for your visit. 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 $35 copayment. for each in-network urgent care center visit. You have been asked to pay a $10 copayment, which is less than the standard copayment, for the urgent care visit. The urgent care visit falls within the "Urgently needed 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 copayment for the urgent care visit provided on December 5, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the nasal/sinus endoscopy with biopsy, polypectomy or debridement provided on December 31, 2019.

You asked the Plan to pay for the nasal/sinus endoscopy with biopsy, polypectomy or debridement. You say that you were on hospice at the time of these services, but this diagnosis is unrelated to your hospice diagnosis. The Plan denied your request. The Plan says that Original Medicare is responsible for the hospice services that are related or unrelated to your hospice diagnosis.

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 nasal/sinus endoscopy with biopsy, polypectomy or debridement provided on December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 12, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the vitamin D testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 5, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 has network providers 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 December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an addition, endoskeletal system, below knee, flexible protective outer surface covering system (L5962) for the enrollee.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that there is no documentation that supports that the member's activity subjects him to harsh environmental situations or that he engages in any extraordinary activities that would justify the need for extra protection with a flexible outer surface covering system.
The Plan must follow Medicare rules. Medicare rules say that the protective outer surface covering system is used by a beneficiary who has special needs for protection against unusually harsh environmental situations. We looked at the file and Medicare rules. The record does not show the enrollee is subject to harsh environmental situation. 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 pre-approve an addition, endoskeletal system, below knee, flexible protective outer surface covering system (L5962) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services (97014, 97110) provided on September 16, 2019 to September 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON physical therapy services. You say that these services were medically necessary. The Plan denied your request. The Plan says these 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 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 physical therapy services (97014, 97110) provided on September 16, 2019 to September 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 deductible for vision care provided on December 16, 2019.
You asked the Plan to waive the deductible for vision care. You say that you disagree with the additional charges and should only owe a $45 copayment. 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 vision care. You received vision care on December 16, 2019. The record shows that you had paid $0 toward the $250 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $129.33. The item or service you asked the Plan to waive the deductible for falls within the benefit category vision care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for vision care. This cost sharing is a contractual obligation that had not been met at the time vision care was received on December 16, 2019. Therefore, we decided that the Plan does not have to waive the deductible for vision care provided on December 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on December 3, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.
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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS(any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA,EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3)method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." We find that HCPCS code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on December 3, 2019.