Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure, endodontic therapy, and resin-based composite.

You asked the Plan to pay for the preventive procedure, endodontic therapy, and resin-based composite. You say that you needed these services provided. The Plan denied your request. The Plan says the preventive procedure and endodontic therapy are not covered services. The Plan also says that your benefits for the resin-based composite have been satisfied and the frequency limitation has been exceeded.

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 preventive procedure and endodontic therapy are not among those covered under this benefit. The contract says that restorations (fillings) are limited to two procedures per calendar year. The record shows that you received two resin-based composites, and your restorations benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the preventive procedure, endodontic therapy, and resin-based composite.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services could have been provided in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 lab work provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of admission to a LTACH does not meet the requirements for approval.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that based on the documentation provided, the health Plan's denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an ACH for small bowel obstruction, which was surgically treated then complicated by an anastomotic leak. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has since been weaned from the ventilator and had her tracheotomy capped. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs.

We looked at this physician's review, the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride.

You asked the Plan to waive the copayment for the ambulance ride. You say that you would like the claim reprocessed because the enrollee was non-ambulatory after his hospital stay and was unable to be put in a car. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $240 copayment per date of service regardless of the number of ground ambulance trips for an in-network non-emergency ambulance. For this date of service, you have been asked to pay the allowed amount which is less than the standard copayment amount for the ambulance ride.

The enrollee has been asked to pay a $148 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance service" benefit category. 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 ambulance ride.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services.

You asked the Plan to waive the copayment for ambulance services. You say that you should only owe $200. 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 $300 copayment for ambulance services.

You have been asked to pay a $300 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays and prophylaxis provided by an OON provider.

You asked the Plan to pay for the bitewing x-rays and prophylaxis. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that services performed by an OON provider are not covered because your healthcare plan does not have OON benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays and prophylaxis provided by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services.

You asked the Plan to pay for dermatology services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the rendering facility or provider are not network providers. The Plan says that prior authorization was not obtained by a participating provider.

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 dermatology services provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for an influenza vaccination visit.

You asked the Plan to pay for flu shot. You say that you should be covered for the influenza vaccine. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because this vaccine is not covered by Medicare Part B and may be covered by your Medicare Part D prescription drug benefits.

The Plan follows Medicare rules. Medicare rules state that most immunizations are not covered unless they are directly related to the treatment of an injury or direct exposure to a disease or condition. However, the influenza virus vaccine is an exception to this rule and is covered by Medicare Part B. Your contract with the Plan states that the Plan covers the influenza vaccine once each flu season in the fall and winter.

The influenza vaccine you received is covered by Medicare Part B. This vaccine was provided to you, which is within the Plan's covered period of the seasons of fall and winter. These services were obtained from an in-network provider. The Plan has not provided any other justification for their decision to deny payment for this claim. Therefore, we decided that the Plan has to pay for an influenza vaccination visit.

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 office visit (99203) provided by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that these services were medically necessary, and this provider is in-network. The Plan denied your request. The Plan says this provider is not in the network for this plan. Out of network services are only covered in limited circumstances.

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 office visit (99203) provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is 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 in the Medicare rules section 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 enrollee was admitted to the hospital after a fall at home with left shoulder pain and acute on chronic kidney disease. She received oral medications and had stable vital signs. She received physical and occupational therapy in the hospital and needs assistance with functional mobility, including gait to 300 feet with a rolling walker. She needs varied assistance with activities of daily living. She has no skilled nursing needs. She has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not 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 a skilled nursing facility (SNF) admission.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy.

You asked the Plan to waive the copayment for a colonoscopy. You say that you thought that you would not
owe anything for a colonoscopy. 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 outpatient surgery, including services provided in an ambulatory surgical center or an outpatient
hospital facility.

The medical records show that you had polyps removed during a colonoscopy. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $250 copayment.

You have been asked to pay a $250 copayment for a colonoscopy. A colonoscopy falls within the outpatient
surgery, including services provided in an ambulatory surgical center or an outpatient hospital facility benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for a colonoscopy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit or the Part B drugs.

You asked the Plan to waive the cost share for the office visit and the Part B drugs. You say that you never saw a doctor and that the shots were given to you by a nurse. You say you have never been billed for the vitamin D shot or the flu shot before. 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 $5 copayment for each in-network covered primary care provider (PCP) office visit and 20% coinsurance for in-network chemotherapy and other drugs covered by Medicare Part B.

You have been asked to pay a $5 copayment for the office visit and $4.84 which is 20% of the allowed amount for the Part B drugs. The allowed amount is $24.24. ($24.24 x 20% = $4.84). ($5 + $4.84 = $9.84). The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Part B drugs fall within the "Medicare Part B prescription drugs" benefit category. The record shows you received services in a primary care physician's office. Please note, you were not charged for the flu shot.

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 cost share for the office visit or the Part B drugs.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the psychological evaluation (96130, 96131, 96137, 96136).

You asked the Plan to waive the copayment for the psychological evaluation. You say that you had this evaluation in order to be approved for another medical service. You felt the provider asked too many questions about suicide and do not feel he provided the correct diagnosis. The Plan denied your request. The Plan says a standard psychological evaluation was provided, and medical records were submitted. Outpatient mental healthcare services are subject to a $40 copayment.

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 for outpatient mental health care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography ultrasound imaging service (93306).

You asked the Plan to waive the copayment for the imaging service. You say that this service was medically necessary, and you believe the Plan should cover it. The Plan denied your request. The Plan says the service is covered but is subject to a $100 copay. The Plan also documented that they called the facility that provided the service in question and confirmed that you are only being billed for the $100 copayment 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 $100 copayment for diagnostic procedures and tests provided in an outpatient hospital facility.

You have been asked to pay a $100 copayment for the imaging service. This imaging service was provided in an outpatient hospital facility and falls within the diagnostic procedures and tests 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 echocardiography ultrasound imaging service (93306).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA 1 and 2 testing for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no personal history of breast, ovarian, fallopian tube, primary peritoneal,
pancreatic, or prostate cancer.
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 services, is being 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 pre-approve
BRCA 1 and 2 testing for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429) provided on October 14, 2020.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because this service was billed per Medicare guidelines. The Plan denied your request. The Plan says this claim was not billed according to CMS guidelines.
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 A0429 is not supported in the record. Specifically, this service was not billed with the appropriate CPT code. The record indicates that the member was pronounced dead after the ambulance was called. In this circumstance, providers must report CPT code A0428. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0429) provided on October 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 30, 2020.
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 services are not authorized, because predictive screening testing is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found labs were drawn for the following: Hgb A1C, Cystatin, HGH, T3, Progesterone, Cortisol, Estradiol, Gonadotropin, FSH, LH, insulin, PTH, thyroid antibodies, C-peptide, Aldolase, Somatomedin. Testosterone, SHBG, DHEA, NT-pro BNP, Cr, BUN/Cr ratio, eGFR. The provided diagnoses and provided documentation do not support any of these tests listed above. There was no clinical indication suggesting an existing condition to warrant the above tests. Therefore, this request for such will be considered not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory work.

You asked the Plan to waive the deductible for the laboratory work. You say that the laboratory work is a part of your annual physical and you should not be charged. 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. Your contract with the Plan says that there is a $250 deductible that applies towards outpatient laboratory work.

The laboratory work you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible that applies towards outpatient laboratory work. This cost sharing is a contractual obligation that had not been met at the time the laboratory work. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory work.