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

We decided that the Plan does not have to pay for the laboratory services provided on November 16, 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 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 was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services provided on November 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the lab services provided on January 22, 2021.

You asked the Plan to waive the cost share for the services provided. You say that the tests should have been covered. The Plan denied your request. The Plan says the claim processed correctly.

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 $203 deductible. 

The services you asked the Plan to waive the cost share for falls within the outpatient diagnostic tests benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible. This cost sharing is a contractual obligation that had not been met at the time the services were received. Therefore, we decided that the Plan does not have to waive the cost share for the lab services provided on January 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery.
You asked the Plan to pre-approve Vertiflex surgery. You say that this requested service is medically
necessary. The Plan denied your request. The Plan says medical studies have not proven that the device is
helpful for treatment of the enrollee's health problem.
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 pre-approve Vertiflex surgery. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental. More research is needed to show the safety and
efficacy of the device before coverage can be approved.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex surgery have not been met. Therefore, we decided that the Plan does
not have to pre-approve Vertiflex surgery.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided out of network on July 22, 2020.
You asked the Plan to pay for out of network services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have a referral and/or prior authorization for 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 Plan contract states that outpatient mental health care requires both a referral from your primary care physician and prior authorization. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. You did not have a referral. 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 outpatient mental health care provided out of network on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Medicare-covered eye exam provided on
January 6, 2021.
You asked the Plan to waive the copayment for the Medicare-covered eye exam. The Plan denied your request.
The Plan says the copay was correctly applied for vision 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). Your contract with the Plan clearly says that you must pay $50
copayment for vision care, Medicare-covered exams.
You have been asked to pay $50 copayment for the Medicare-covered eye exam. The Medicare-covered eye
exam falls within the vision care, Medicare-covered exams 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 Medicare-covered eye exam provided on January 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from December 26, 2020, through December 31, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that most of the time you were waiting for an MRI. You say that you cannot afford such a large bill. 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 $370 a day copayment for days 1-5 for each inpatient admission; this includes medical, surgical and rehabilitation services.
You have been asked to pay a $1,850 for the inpatient stay. ($370/day x 5 days = $1,850). 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 December 26, 2020, through December 31, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physicians services provided to the enrollee on May 7, 2020.
You asked the Plan to pay for May 7, 2020. You say that this claim should be paid. The Plan denied your request. The Plan says while May 6, 2020 was paid, the enrollee entered hospice on May 7, 2020 and therefore that date of service must be submitted to Original Medicare for review.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physicians services provided to the enrollee on May 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on September 14, 2020, through September 16, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was 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 per each day one through seven for inpatient hospital care. You have been asked to pay a $200 copayment per each day one through seven for inpatient hospital care. This service 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 inpatient hospital care provided on September 14, 2020, through September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received
December 4, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were a new patient with this
dentist and did not know that you should not have received this requested service. The Plan denied your
request. The Plan says the requested service has a frequency limit of one procedure every three 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. The Plan covers the
comprehensive oral evaluation when the services are medically necessary and reasonable.
We looked at the file, and Medicare rules. The Plan has submitted evidence that you received a comprehensive
oral evaluation on March 6, 2019. Your benefit for this service was exhausted when it was received on
December 4, 2020. Based on this information, we decided that the Plan's rules for coverage of the
comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for
the comprehensive oral evaluation (D0150) received December 4, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee August 26, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare data base shows the enrollee was in hospice from August 22, 2020, to August 25, 2020.

The Plan says that in accordance with Medicare guidelines, the provider needs to bill Original Medicare, using the proper modifiers, for services rendered on August 26, 2020. Per the regulations above, the member's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. It is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee August 26, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the emergency ambulance service (A0427) and ground mileage (A0425) provided on October 13, 2020.
You asked the Plan to pay for the emergency ambulance service and ground mileage. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says that the information provided does not support medical necessity for ambulance transport.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 emergency ambulance service and ground mileage. Our reviewer says that these services meet coverage criteria. Our physician reviewer found given the recent diagnosis of pneumonia in this elderly enrollee, the symptoms of vomiting and diarrhea could be considered emergent. Our reviewer found that it is more likely to lead to hypotension and dizziness if a lot of fluid is lost and the enrollee cannot be seen fit to be transported by means other than paramedics. Our physician reviewer also found that even if vitals at time of evaluation are normal, they can change quickly especially if the infection is COVID. 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 emergency ambulance service and ground mileage have been met. Therefore, we decided that the Plan has to pay for the emergency ambulance service (A0427) and ground mileage (A0425) provided on October 13, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from November 25, 2020,
through December 1, 2020.

You asked the Plan to pay for an inpatient admission provided from November 25, 2020, through December 1,
2020. The Plan denied your request. The Plan says the criteria is not met under InterQual 2020 LOC: Acute
Adult; Subset: General Medical under Gastrointestinal or Biliary criteria.

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 an inpatient admission provided from
November 25, 2020, through December 1, 2020. Our reviewer says that the acute level of care for dates of
service from November 25, 2020, through December 1, 2020 are not considered medically reasonable and
necessary in this case. Our physician reviewer found that the enrollee was a then 82-year-old male who
presented to the hospital on November 23, 2020 for increased confusion. The enrollee underwent biochemical
testing and imaging studies, and thereafter was admitted to the med/surg floor for further evaluation and
management. After review, the acute level of care with dates of service November 25, 2020, through
December 1, 2020 did not meet InterQual 2020 LOC: Acute Adult; Subset: General Medical under
Gastrointestinal or Biliary criteria. There were no acute findings that would warrant inpatient stay. There was
no ascites, hepatic encephalopathy, ileus, jaundice, or pancreatitis chronic. The enrollee was responding to
treatment and was clinically stable for transfer or discharge. Medical necessity has not established for the dates
of service November 25, 2020, through December 1, 2020. The services could have been rendered at lower
level of care. The review has determined that the ongoing inpatient care from November 25, 2020, through
December 1, 2020 was not medically reasonable or necessary and the enrollee could have been discharged to a
lower 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 an inpatient admission provided from November 25, 2020, through
December 1, 2020. have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient
admission provided from November 25, 2020, through December 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the orbit, face, and neck for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee had the same test (or one like it) on May 10, 2021.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found that in this case, the enrollee may be suffering from chronic sinusitis or recurrent acute sinusitis. In either case, when the symptoms are not improving with standard medical management, then imaging may be indicated. This standard of care is to obtain a CT sinus without contrast. A MRI of the sinuses is indicated if there are abnormal findings on CT such as invasion of surrounding structures, concern for a skull base defect, nasopharyngeal mass, or other concerning findings. In this case, the MRI face is not indicated. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the orbit, face, and neck for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your request. The Plan says this would be considered a convenience item and not covered.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate upper denture (D5130) and the immediate lower denture (D5140) provided on December 12, 2019.

You asked the Plan to pay for the dental items. You say that the wrong dentist was paid. You say that the provider submitted a false claim. You also say that you still do not have dentures and the provider will not reverse the claim. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit 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 and dentures are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for dentures that you physically received on August 12, 2019. The record shows that you were receiving adjustments on the initial set of dentures as late as November 2019. Therefore, we decided that the Plan does not have to pay for the immediate upper denture (D5130) and the immediate lower denture (D5140) provided on December 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) and endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided January 15, 2021.
You asked the Plan to pay for the dental consultation and endodontic therapy. You say that you were told you could see any dentist. The Plan denied your request. The Plan says the dentist who rendered the services is not part of the Plan's network and therefore the services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental consultation and endodontic therapy when the services are provided by a network provider. We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the
Plan at the time of the service. 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. Based on this information, we decided that the Plan's rules for coverage of the dental consultation and endodontic therapy have not been met. Therefore, we decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) and endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided January 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 16, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on November 16, 2020.