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

We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 7, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the provider is not in-network and there is no authorization on file 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 did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on January 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two extractions provided on January 27, 2020 by an
OON provider.
You asked the Plan to pay for the extractions. You say that this provider is in network. The Plan denied your
request. The Plan says the services were rendered by a non-contracted provider. The Plan also says that you
contacted the Plan prior to the services being rendered and were told that this treating provider is OON.
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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the two
extractions provided on January 27, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on February
13, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that you should not be
responsible for this copayment because the laboratory work has related to your annual physical exam. 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 $10
copayment for Medicare-covered laboratory tests. This copayment does not apply to blood draws or INR
testing (anti-coagulant testing). You will only pay one copayment per day even if multiple lab tests are
performed.
You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the
laboratory work is considered a separate service.
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 laboratory work provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 9, 2020.
You asked the Plan to pay for the laboratory 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 laboratory 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 laboratory services provided on January 9, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided from January 17, 2020 to January 18, 2020.You asked the Plan to waive the copayment forthe emergency room visit. You say that you would like this charge reviewed because you had a serious emergency. You say you were admitted for observation. 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 for each 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. The record shows that the status of your hospital services was Outpatient Observation. 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 emergency room visit provided from January 17, 2020 to January 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 13, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (G0249) provided on January 13, 2020, and January 27, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the frequency limitation has been exceeded.The Plan must follow Medicare rules. Medicare rules say that G0249 is allowed once every 25 days.We looked at the file and Medicare rules. The records show that the plan processed and paid a claim for code G0249 for date of service January 5, 2020. The requested services were provided within 25 days of the paid service, and therefore exceed the frequency limit. 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 topay forthe services (G0249) provided on January 13, 2020, and January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shingles vaccine you received on September 25, 2019.You asked the Plan to pay forthe vaccine. The Plan denied your request. The Plan says this is not a covered benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine.Therefore, we decided that the Plan does not have to pay forthe shingles vaccine you received on September 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services
cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering
physician's intent that the tests be performed. 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 the
drug testing services provided on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on March 20, 2018 by an out of network (OON) provider.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says that you do not have out of network benefits.
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 dental services provided on March 20, 2018 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from November 27, 2019 through December 2, 2019. You asked the Plan to waive the copayment for the inpatient stay. You say that you were supposed to be
discharged sooner. You say that it's unfair to pay the two extra days. 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 $285 copayment per day, per stay for days 1-6. You have been asked to pay a $1,425 copayment for the inpatient stay. ($285/day x 5 days = $1,425). The inpatient stay falls within the "Inpatient hospital 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 inpatient stay provided from November 27, 2019 through December 2, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond June 18, 2020.
You asked the Plan to pre-approve these services. You say that you have difficulty walking and standing up and need additional therapy. The Plan denied your request. The Plan says the continued services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the submitted records show that you were admitted to the SNF on June 10, 2020. You received oral medications and had stable vital signs. You received physical, occupational, and speech therapy in the SNF. You are able to walk 150 feet with a rolling walker and need varied levels of assistance with activities of daily living. You have no skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you no longer require the necessary services on an inpatient basis at the SNF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on February 10, 2020.You asked the Plan to waive the copayment for the laboratory services. You say that you do not understand the charge for the laboratory work. You say you have never seen charged prior for laboratory work. 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 $15 copayment per visit for laboratory tests, non-radiological tests, diagnostic tests, flat film x-rays, and ultrasounds. You have been asked to pay a $15 copayment for the laboratory services. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the laboratory services provided on February 10, 2020.Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from March 4,
2020 through March 6, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you can't afford the payments.
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 $200
copayment for each inpatient admission; this includes medical, surgical and rehabilitation services.
You have been asked to pay a $200 copayment for the inpatient stay. The inpatient stay falls within the
"Inpatient hospital 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 inpatient
stay provided from March 4, 2020 through March 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transport chair.
You asked the Plan to pre-approve a transport chair. You say that the enrollee needs a transport chair to get to and from doctor appointments and the grocery store. The Plan denied your request. The Plan says a wheelchair is not approvable if reason is for outside of home use.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers wheelchairs for use only outside the home. Therefore, we decided that the Plan does not have to pre-approve a transport chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350), comprehensive oral evaluation (D0150), and complete series of intraoral x-rays (D0210) provided on February 6, 2020.
You asked the Plan to pay for the 2D oral/facial photographic image, comprehensive oral evaluation, and complete series of intraoral x-rays. You say that you would like to know if the charges for the first service can be overridden so you would not have any charges. The Plan denied your request. The Plan says 2D oral/facial photographic image is not a covered benefit. The Plan also says that you have exceeded the limits set in the subscriber agreement for the comprehensive oral evaluation and complete series of intraoral x-rays.
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, 2D oral/facial photographic image is not among those covered under this benefit. The contract also clearly states that comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years.
The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on January 20, 2020 and your comprehensive oral evaluation and complete series of intraoral x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350), comprehensive oral evaluation (D0150), and complete series of intraoral x-rays (D0210) provided on February 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has been shown to meet the necessary criteria to approve this request.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found he provided medical records do not indicate a need for skilled nursing services or skilled therapy services. The provided medical records do not indicate a need for daily skilled services. There is no need indicated for inpatient services. Care in the home or an assisted living facility with home health services appears to be appropriate. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis, the knee orthosis and suspension sleeve provided on January 6, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650), the knee orthosis (L1833) and suspension sleeve (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not 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 for the lumbar-sacral orthosis, the knee orthosis and suspension sleeve provided on January 6, 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 this is the most appropriate discharge disposition for the enrollee. The Plan denied your request. The Plan says the enrollee could receive care in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 submitted medical records do not indicate that there are significant or complex medical or nursing issues that could not be addressed at a skilled nursing facility level of care. It is not clear that the enrollee would be able to fully benefit or participate in an IRF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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.