Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for the apolipoprotein services. We decided that the Plan does not have to waive the copay for the lab services.
You asked the Plan to pay for the lab services. You say that you are trying to find something you can tolerate. The Plan says that Medicare does not cover services or supplies not considered reasonable or necessary.
We decided that the Plan has to pay for the apolipoprotein lab services.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.
You were referred for the apolipoprotein lab testing by a contract provider. The file does not show that the Plan provided notice that the service at issue would not be covered. Under Medicare rules, this means the service is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the apolipoprotein lab services provided on October 21, 2020.
We also decided that the Plan does not have to waive the copay for the lab services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
You have been asked to pay a $10 copay for the lab services. The services fall within the outpatient diagnostic testing 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 copay for the lab services provided on October 21, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 10, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 did not pre-approve the physician's services. We found no exception that would require the Plan to pay for the physician's services. Therefore, we decided that the Plan does not have to pay for physician's services provided on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scalings and root planings provided on
October 1, 2020, and October 21, 2020.
You asked the Plan to pay for the scalings and planings. You say that you were told that these services would
be covered. The Plan denied your request. The Plan says you have exhausted your $200 benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan will cover up to $200 for any
dental services that are not covered in the preventive services section. The record shows that you met the
annual maximum benefit on October 1, 2020, and your annual maximum benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the periodontal scalings and root planings
provided on October 1, 2020, and October 21, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to hold you harmless for the assay of homocysteine services received on November 23, 2020.
You asked the Plan to hold you harmless for the assay of homocysteine services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services received are not a covered benefit.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You received the assay of homocysteine services by a contract provider. The file does not show that the Plan provided notice that the assay of homocysteine services would not be covered. Under Medicare rules, this means the assay of homocysteine services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the assay of homocysteine services received on November 23, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical service provided on December 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the wound care. You say that the wound care was medically necessary. The Plan denied your request. The Plan says 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 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 the medical service provided on December 4, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted ambulance service (A0999) provided April 27,
2020.
You asked the Plan to pay for unlisted ambulance service. You say that you are a separate entity from the
hospital and doctors and do not have access to sending their records. Please process your claim for payment.
The Plan denied your request. The Plan says payment of ambulance supplies is not a covered benefit because
payment is included in the transport fee, which has been approved for payment.
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 A0999 is unlisted ambulance service.
We find that payment for these items is included in the payment for the ambulance transport. Medicare does
not allow for separate billing of these services and supplies. Based on this information, we decided that
Medicare rules for coverage of unlisted ambulance service have not been met. Therefore, we decided that the
Plan does not have to pay for unlisted ambulance service (A0999) provided April 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride, excluding varnish
provided on November 11, 2020.
You asked the Plan to pay for the topical application of fluoride, excluding varnish. You say that you would
like this service to be covered. The Plan denied your request. The Plan says this service is not covered. The
Plan also says that prior to the date of service you did not contact the Plan to verify benefits and provider
eligibility.
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
topical application of fluoride, excluding varnish provided on November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services.

You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

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 surgical pathology services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 7, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent,
non-urgent services with out-of-network providers require prior authorization.
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
physician's services. 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 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99202), x-ray exam of the lumbar spine (72100), and the x-ray exam of the cervical spine (72040).

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not covered under your contractual policy or by Medicare.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99202), x-ray exam of the lumbar spine (72100), and the x-ray exam of the cervical spine (72040).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0140) and intraoral radiographic
images (D0220) provided on September 10, 2020.
You asked the Plan to pay for the oral evaluation and intraoral radiographic images. You say that you would
like reconsideration because you went to your dentist for a toothache and the provider rendered an exam, took
an x-ray and prescribed an antibiotic. The Plan denied your request. The Plan says two oral evaluations are
covered per year and CPT code D0220 is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested intraoral x-ray is not
among those covered under this benefit. Additionally, the record indicates that you received two oral
evaluations prior to the evaluation at issue. Two oral evaluations are covered per year. Therefore, we decided
that the Plan does not have to pay for the oral evaluation (D0140) and intraoral radiographic images (D0220)
provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for influenza virus vaccine provided on October 6, 2020.
You asked the Plan to pay for the influenza virus vaccine. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 did not pre-approve the influenza virus vaccine. 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 influenza virus vaccine provided on
October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 21, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 did not pre-approve the physician's services. 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 September 21, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the coinsurance for surgery services.

You asked the Plan to waive the coinsurance for surgery services. You say that you have a dual eligibility plan and should not be billed for any portion. The Plan denied your request. The Plan says that the coinsurance applied correctly, and the provider must bill Medicaid directly for the remaining portion.

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 enrollees pay $0 for surgery services at an in-network specialist's office.

The Plan says you must pay 20% coinsurance for surgery services on each date of service. Based on the Plan contract, however, you cannot be asked to pay more than $0 for surgery services. Therefore, we decided that the Plan has to waive the coinsurance for surgery services.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the power wheelchair provided on April
29, 2020.
You asked the Plan to waive the coinsurance for the power wheelchair. You say that you were told your
wheelchair was covered. The Plan denied your request. The Plan says you have been asked to pay 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 20% of
the plan-allowed amount for in-network Medicare-covered durable medical equipment.
You have been asked to pay $93.99 which is 20% of the allowed amount for the power wheelchair. The
allowed amount is $469.96. ($469.96 x 20% = $93.99). The power wheelchair falls within the "Durable
medical equipment (DME) and related supplies" 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 the power wheelchair provided on April 29, 2020.
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 your care can be safely met at a lower 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 weakness and pneumonia. Your medical problems 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automated blood pressure cuff.
You asked the Plan to pre-approve the automated blood pressure cuff. You say that you were given a script by your cardiologist. You say that it would help you financially if this was covered. The Plan denied your request. The Plan says blood pressure monitors are not covered.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automated blood pressure cuff.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for anesthesia services (01992) provided on September 21, 2020.
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration because there has been an incorrect interpretation of coding guidelines. The Plan denied your request. The Plan says that CPT code 01992 has a status code of J and is not payable by Medicare.
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 01992 is supported in the record. Specifically, CPT code 01992 is payable under the Anesthesia Fee Schedule. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have been met. Therefore, we decided that the Plan has to pay for anesthesia services (01992) provided on September 21, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the computed tomography (CT) scan of the upper extremity (73201).

You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $225 copayment for each Medicare-covered advanced imaging service (not including x-rays).

You have been asked to pay a $225 copayment for the advanced imaging service provided. 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 adjust the copayment for the computed tomography (CT) scan of the upper extremity (73201).