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

We decided that the Plan does not have to pay for an office visit provided on January 22, 2021 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on January 22, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received December 28, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you had not had a dental visit in over 14 months due the pandemic. The Plan denied your request. The Plan says your benefit is limited to one comprehensive oral evaluation (D0150) every three plan years.
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 is in excess of that covered under this benefit. The Plan covers comprehensive oral evaluations once every three plan years. The Plan has submitted evidence that you last received this service October 8, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received December 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on July 23, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because you had COVID-19. 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 ambulance services. You received ambulance services on July 23, 2020. Ambulance services are included in the COVID-19 waiver. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay fora dental cleaning (D1110), periodic oral evaluation (D0120) and bitewing x-rays (D0272) provided on July 9, 2020.You asked the Plan to pay forthe dental services. You say that your Plan does cover out of network oral exams, cleaning and x-rays at least once a year. You provided a copy of the summary of benefits that was sent to you by the Plan.The Plan denied your request. The Plan says that supplemental dental benefits should be obtained from a provider in the dental Plan's network. The provider you used is not a contracted provider.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 does not say in clear and accurate terms that you are responsible for the full cost of preventative dental services when they are provided out-of-network. We looked at your contract with the Plan. We did not see where the contract says that out-of-network preventative dental care is not covered. The Plan contract states that preventative dental services, including up to two routine dentalexams, two cleanings and one x-ray can be covered per year. The contract states that there is a $0 copayment for each of these services when they are provided in-network, and a $0 copayment when they are provided out-of-network. The contract states that enrollees "should" use a provider in the Plan's dental network, however it does not state that they must use a provider in the network or state that services provided outside the dental network will not be covered. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information.We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met.Therefore, we decided that the Plan hasto pay fora dental cleaning (D1110), periodic oral evaluation (D0120) and bitewing x-rays (D0272) provided on July 9, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 29, 2020, to
December 2, 2020.
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says
that inpatient care was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 pay for the acute inpatient hospital care. Our
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our
physician reviewer found that the record did show that at the time of inpatient admission the admitting
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or
observation care) would span two midnights.
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 acute inpatient hospital care have been met. Therefore, we decided that the
Plan has to pay for the acute inpatient hospital care provided from November 29, 2020, to December 2, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an oxygen concentrator (E1392) with battery (E1399) and shipping charge purchased on October 8, 2020.
You asked the Plan to pay for an oxygen concentrator with battery and shipping charge. You say that you depend completely on the requested oxygen concentrator. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator with battery and shipping charge have not been met. Specifically, the item at issue was purchased rather than rented. The requested battery is not separately payable when the base item is not covered. Shipping charges are not separately payable. Therefore, we decided that the Plan does not have to pay for an oxygen concentrator (E1392) with battery (E1399) and shipping charge purchased on October 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an automated external defibrillator garment (Lifevest) provided on October 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for Lifevest. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this item is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an automated external defibrillator garment (Lifevest) provided on October 8, 2020 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 September 10, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you shouldn't be charged because your primary care physician told you to go to an urgent care facility. You say that this would have been covered in full if your doctor was available. 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 $50 copayment per visit for Medicare-covered urgently needed services. You have been asked to pay a $50 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 September 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on June 15, 2020.
You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing required information.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows that the proof of delivery did not include an itemize order form or invoice to indicate the specific supplies; therefore, the billed supply code cannot be verified. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device provided on August 12, 2020.
You asked the Plan to pay for the intermittent limb compression device (E0676). You say that the equipment was ordered by the surgeon for use during surgery. The Plan denied your request. The Plan says Medicare does not pay any provider or supplier other than the hospital for services furnished to the enrollee while an inpatient in the hospital.
The Plan must follow Medicare rules. Medicare rules say that 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 made with outside providers. This equipment was used during and after a surgical procedure by the facility. Payment for this service would have been included under the global facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, the Plan is not required to pay this claim. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device provided on August 12, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the first 2 hours of home infusion administration (99601) and each additional hour of home infusion administration (99602) provided on August 13, 2020.
You asked the Plan to pay for the first 2 hours of home infusion administration and each additional hour of home infusion administration. You say that the services that were provided are appropriate for the level of acuity and intensity of the Medical services provided and for the expertise required to provide these services. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the billed code is not valid for Medicare purposes and is not covered.
The Plan must follow Medicare rules. Medicare rules say that procedure codes 99601 and 99602 are not valid for Medicare purposes and are not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the first 2 hours of home infusion administration and each additional hour of home infusion administration have not been met. Therefore, we decided that the Plan does not have to pay for the first 2 hours of home infusion administration (99601) and each additional hour of home infusion administration (99602) provided on August 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammogram you had on November 19, 2020.
You asked the Plan to pay for the mammogram. The Plan denied your request. The Plan says you have exceeded the benefit limit.
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 $0 copayment for one screening mammogram every 12 months. Review of the file shows that you had a screening mammogram on November 19, 2020. This service is only covered once every 12 months. The records also show that you had a covered screening mammogram on January 6, 2020. The requested mammogram exceeds the benefit limit. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the mammogram you had on November 19, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the health behavior assessment provided on February 25, 2020.
You asked the Plan to waive the copayment for the health behavior assessment. You say that you have never paid to see this mental health care provider. You say you saw him 1-2 times in 2020 or 2019. 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 a $35 copayment per individual or group visit for outpatient mental health care. You have been asked to pay a $35 copayment for the health behavior assessment. The health behavior assessment falls within the "Outpatient mental health 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 health behavior assessment provided on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
You asked the Plan to pre-approve the complete maxillary denture. You say that you would like this denture to be approved. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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, complete maxillary denture (D5110) is limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) on June 14, 2019 and your complete maxillary denture (D5110) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a referral to a dermatologist.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says that the notes do not describe a question about your condition.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 referral. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you have a skin lesion on the breast that needs to be evaluated by a dermatologist for possible malignancy. 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 referral have been met. Therefore, we decided that the Plan has to pre-approve a referral to a dermatologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a humidifier (E0560).
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a humidifier (E0560).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (HCPCS A9276, A9277, A9278).
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says there is no support for a non-therapeutic monitor.
The Plan must follow Medicare rules. The rules say that HCPCS A9276, A9277, and A9278 are not covered codes. The requested monitor is coded in such a way that makes it statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (HCPCS A9276, A9277, A9278).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on November 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 physician services provided on November 5, 2020 by an out of network (OON) provider.