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

We decided that the Plan does not have to pay forthe medical services provided on May 26, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe rest home visit. You say that you would like reconsideration because these services were medically necessary and rendered in good faith.The Plan denied your request. The Plan says these services were not urgent, emergent or approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forthe medical services provided on May 26, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on June
14, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that you feel you should not
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan
denied your request. The Plan says you received ambulance services on the date of service at issue in this
appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $325
copayment for Ambulance services.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received ambulance
services on June 14, 2020. You have been asked to pay a $325 copayment for the ambulance services. The
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 the ambulance services provided on June 14, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve BCR-ABL genetic testing.
You asked the Plan to pre-approve the BCR-ABL genetic testing. You say that you would like reconsideration
because this testing is medically necessary. The Plan denied your request. The Plan says that the member does
not have abnormal labs and the documentation does not show how this testing will change treatment or other
diagnostic testing.
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 BCR-ABL genetic testing. Our
reviewer says that BCR-ABL testing is most often used to diagnose chronic myeloid leukemia or a form of
acute lymphoblastic leukemia. Our physician reviewer found it is considered medically reasonable and
necessary to evaluate for a lymphoproliferative or myeloproliferative disorder in an enrollee with an elevated
white blood cell count.
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 BCR-ABL genetic testing have been met. Therefore, we decided that the
Plan has to pre-approve BCR-ABL genetic testing.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the intraroral X-rays
(D0220), and adult dental cleaning services (D0120) provided on August 11, 2020, by a provider who has
opted-out of Medicare.
You asked the Plan to pay for the periodic oral evaluation, the intraroral X-rays, and adult dental cleaning
services. You say that you would like this claim reprocessed and approved. The Plan denied your request. The
Plan says no payment can be made to a provider who has opted-out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the
periodic oral evaluation (D0120), the intraroral X-rays (D0220), and adult dental cleaning services (D0120)
provided on August 11, 2020, by a provider who has opted-out of Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical
x-ray (D0230), the limited oral evaluation (D0140), the filling (D2331), and the root canal (D3310) provided
on September 21, 2020.
You asked the Plan to pay for the dental services. You say that you called the plan to confirm that the dentist
was in network. You say that the dentist is in network based on the website too. You also say that the provider
office confirmed they were within the Plan's PPO network. The Plan denied your request. The Plan says the
provider in this case is out of network. The Plan says that dental services that you receive out of network are
not covered. The Plan also says that the limited oral evaluation, periapical x-rays, and root canal are not listed
as covered services.
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, dental services that you receive out of
network are not covered. Therefore, we decided that the Plan does not have to pay for the initial periapical xray
(D0220), the additional periapical x-ray (D0230), the limited oral evaluation (D0140), the filling (D2331),
and the root canal (D3310) provided on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infrared therapy (97026) provided on September 3, 2020.
You asked the Plan to pay for the infrared therapy. You say that you are requesting a reconsideration of the
Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit
under the enrollee's contractual policy or by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of this service have not been met. Specifically, infrared therapy is considered not medically
reasonable and necessary by Medicare and is excluded from coverage. Therefore, we decided that the Plan does
not have to pay for the infrared therapy (97026) provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 22, 2020 by a non-participating provider.
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 services were rendered by a non-participating provider without 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 22, 2020 by a non-participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran x-ray (71046) provided September 4, 2020.You asked the Plan to waive the copayment forthe x-ray. You say that the copayment should be waived because of the COVID-19 pandemic.The Plan denied your request. The Plan says the service was not related to COVID-19 and the correct cost-sharing was applied.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 $20 copayment for x-rays. You have been asked to pay a $20 copayment for the x-ray. 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 foran x-ray (71046) provided September 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0425, A0427) provided on January
3, 2020.
You asked the Plan to pay for the ambulance services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says the Medicare hospice benefit, through feefor-service Medicare, covers all hospice care from the effective date of election to the date of discharge or
revocation.
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 the ambulance services (A0425, A0427) provided on January
3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation provided on June 22, 2020.
You asked the Plan to pay for the periodic oral evaluation. You say that your appointment on June 4, 2020 was
for a follow up on a plate and implants that you had received the previous year. You also say that your visit on
June 22, 2020 should be paid per your preventive benefits. The Plan denied your request. The Plan says this
service exceeds the benefit allowance.
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, you are limited to one oral examination
every calendar year. The record shows that you received a periodic oral evaluation on June 4, 2020, and your
oral examination benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the
periodic oral evaluation provided on June 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that a skilled nursing facility will not provide the level of service that the enrollee needs. The Plan denied your request. The Plan says this request is not medically necessary.
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 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. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Our physician reviewer also found that there is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial inpatient consultation (99253) provided to the enrollee on November 13, 2019.You asked the Plan to pay forthe inpatient consultation. You say that these services were medically necessary.The Plan denied your request. The Plan says that this code is not a valid code for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPTcode. In this case, the CPT Code Manual definition of code 99253 is inpatient consultation. The CPT code 99253 has a status "I" indicator as outlined by Medicare billing rules; therefore, is not valid for Medicare purposes. Based on this information, we decided that Medicare for rules coverage of inpatient consultation have not been met.Therefore, we decided that the Plan does not have to pay forthe initial inpatient consultation (99253) provided to the enrollee on November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe fillings for teeth # 2, 13, 29 and 31 provided on August 19, 2020.You asked the Plan to pay forthe fillings. You say that you do not understand why none of the services were paid. You say that no one ever told you about the frequency limitations. You also say that you feel the plan is being unfair.The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that 2 fillings are covered per calendar year. The Plan says you pay a 55% coinsurance for fillings that you receive out of network. The Plan 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, the frequency limit of 2 fillings per calendar year has been exceeded. The record shows that the Plan paid the out of network coinsurance of 45% for the filling on tooth # 2 that you received on the date of service in this case and the filling on tooth # 21 that you received on May 22, 2020.Therefore, we decided that the Plan does not have to pay forthe fillings for teeth # 2, 13, 29 and 31 provided on August 19, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 28, 2020 and September 10, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says he Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 28, 2020 and September 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 the enrollee was admitted to the hospital and for diarrhea, abdominal pain, hypoxia,
and respiratory failure due to COVID-19 pneumonia. The enrollee's hospitalization has been complicated by
sepsis, hypotension, ARDS, acute kidney injury, anemia, hematuria, ventilator associated pneumonia, failure to
wean from the ventilator, and worsening respiratory status. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are
no services available at the LTACH that the enrollee requires that are not available at the health care setting
being offered by the health plan.
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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the device evaluation provided on October 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an OON device evaluation. You say that this should be covered. The Plan denied your request. The Plan says this was not authorized.
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 device evaluation 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 pay for subsequent nursing facility care provided on July 9, 2020.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says prior authorization is required.Medicare rules say that plans can require enrollees to getcare 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 servicesat 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 July 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on August 12, 2020.You asked the Plan to pay forthe ambulance services. You say that you did not request this service.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 12, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on August 12, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services rendered on July 12, 2019.
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 not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for these services was not filed until October 22, 2020. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for the physician services rendered on July 12, 2019.