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

We decided that the Plan does not have to pay forthe fillings (D2391) for teeth # 17 and 32 provided on August 5, 2020.You asked the Plan to pay forthe fillings for teeth # 17 and 32. You say that you were referred to this dental office by a plan representative. You say that the dental office also confirmed that the services would be covered.The Plan denied your request. The Plan says 2 fillings per calendar year are covered. The Plan also says that the frequency limit for fillings 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 for the fillings for teeth # 1 and 16 that you received on the same date of service.Therefore, we decided that the Plan does not have to pay forthe fillings (D2391) for teeth # 17 and 32 provided on August 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on July 4, 2020.You asked the Plan to pay forthe ambulance services. 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 July 4, 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 July 4, 2020
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay forthe screening mammography (77067) provided on July 23, 2020.You asked the Plan to pay forCPT code 77067. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that the services are not covered.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not provided any documentation showing that Medicare payment guidelines have not been met. The file does not show that Medicare will not pay for CPT code 77067 when provided in a place of service code 23. We find that the Plan has not substantiated their reasoning for denial of payment.Therefore, we decided that the Plan has to pay forthe screening mammography (77067) provided on July 23, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) stay provided.

You asked the Plan to pay for the SNF stay. You say that the services provided were medically necessary.The Plan denied your request. The Plan says rules for SNF care have not been met.

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 pay for the SNF stay. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there were no identifiable skilled nursing or skilled therapy service needs. Furthermore, the beneficiary did not require skilled nursing or therapy services on a daily basis and did not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

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 SNF stay have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on June 25, 2020.
You asked the Plan to pay for drug testing. You say that this was billed correctly. The Plan denied your request. The Plan says the records do not support the billed place of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that the billing of this claim is not supported. This claim was billed with POS 81, but the record indicates that the specimen tested was collected in an office setting and the testing was ordered as in-house. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on June 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital care from July 7, 2020, to July 11, 2020.You asked the Plan to waive the copayment foran inpatient hospital care. You say that the stay was related to COVID-19 and you feel that you should not owe a copayment.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 $390 copayment for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from July 7, 2020, to July 11, 2020. Therefore, you are responsible to pay a $390 copayment for days 1-5 (July 7, 2020, to July 10, 2020). $390 (copayment) x 4 (inpatient days) = $1,560. You have been asked to pay a $390 copayment for days 1-5 for an inpatient hospital care. An inpatient hospital care 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 foran inpatient hospital care from July 7, 2020, to July 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on June 17, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your
request. The Plan says the denial of payment for this testing is correct, because the documentation submitted
does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing
was taken in an office setting, therefore the Place of Service (POS) code 81 - indicating an independent
laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules
for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for
laboratory testing provided on June 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing facility (SNF) care from March 12, 2020, through March 23, 2020, and March 30, 2020, through April 10, 2020.You asked the Plan to pay forSNF care. You say that the service was medically necessary.The Plandenied your request. The Plan says from March 12, 2020 through March 23, 2020 and from March 30, 2020 through April 10, 2020, the member no longer required daily skilled care from either a nurse or a therapist. Continued assistance with routine daily activities could be safely provided at the custodial level of care as it had been before.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 pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis and there are no identifiable skilled therapy service 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pay forskilled nursing facility (SNF) care from March 12, 2020, through March 23, 2020, and March 30, 2020, through April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 9, 2020, by an OON provider.You asked the Plan to pay fornursing facility care. You say that the enrollee could not choose an in-network neurologist as no in-network neurologist provides care in the enrollee's place of residence, a nursing home setting.The Plan denied your request. The Plan says rules for payment have not been met.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 forthe medical services provided on August 9, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement of mycotic nails (G0127) provided on July 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the podiatry services. You say that please see the attached office notes. You do not need to get prior authorization for this procedure. Please review this information and pay accordingly. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 debridement of mycotic nails (G0127) provided on July 13, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Integra F.
You asked the Plan to pre-approve Integra F. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Integra F.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran annual wellness visit (G0439) provided August 18, 2020.You asked the Plan to pay forthe annual wellness visit. You say that you thought this exam was covered every 6 months.The Plan denied your request. The Plan says an annual wellness exam is covered once a year.The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is covered for an enrollee who has not had an annual wellness visit providing a personalized prevention plan within the past 12 months. We looked at the file and Medicare rules. The record shows an annual wellness visit was already provided on February 18, 2020. Based on this information, we decided that Medicare rules for coverage of the annual wellness visit have not been met.Therefore, we decided that the Plan doesnot have to pay foran annual wellness visit (G0439) provided August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for eyeglasses providedon August 4, 2020You asked the Plan to reimburse you an additional amount for the eyeglasses. You say that your new eyeglasses are the first pair that youhave purchased in around twenty years and you would think vision care would provide for new eyeglasses after twenty years. The Plan denied your request. The Plan says eyewear benefit only covers up to the maximum allowed amount of $150allowance.Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan paid themaximum allowed benefit amount of $150 for the eyeglasses.Therefore, we decided that the Plan does not have to reimburse you an additional amount for eyeglasses providedonAugust 4, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ophthalmology services provided on August 7, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that prior authorization was not verified at the time of service.The Plan denied your request. The Plan says a prior authorization was not obtained as required.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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these OON services.Therefore, we decided that the Plan does not have to pay forthe ophthalmology services provided on August 7, 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 the physician services provided by an out-of-network provider.

You asked the Plan to pay for the physician services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request 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 has network providers available who can provide the services at issue in this appeal. 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 the physician services provided by an out-of-network provider
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges foran inpatient hospital stay. We decided that the Plan does not have to reduce the cost-sharing charges foran inpatient hospital stayto the amount you requested. You asked the Plan to reduce the cost-sharing charges foran inpatient hospital stay. You say that you were admitteddue to symptoms similar to COVID-19 and you disagree with the charges.The Plan says that the claims were processed correctly and you are being charged the correct amount.We decided that the Planhas to reduce the cost-sharing charges foran inpatient hospital stayfrom $2,100 to $1,500. The plan contract says that you must pay a $300 copayment for days 1-5 for inpatient hospital care. Therefore, we decided that the Plan has to reduce the cost-sharing charges foran inpatient hospital stayfrom $2,100 to $1,500. We also decided that the Plandoes not have to reduce the cost-sharing charges foran inpatient hospitalstayto the amount you requested. 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 youmust pay a $300 copayment for days 1-5 for an inpatient hospital stay.You had an inpatient hospital stay from February 29, 2020, to March 6, 2020. Therefore, you are responsible to pay a $300 copayment for days 1-5 (February 29, 2020, to March 5, 2020). $300 (copayment) x 5 (inpatient days) = $1,500. Therefore, we decided that the Plan does not have to reduce the cost-sharing charges foran inpatient hospital stayto the amount you requested. 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 waive the copayment for a podiatrist office visit (99203) on July 14, 2020.
You asked the Plan to waive the copayment for a podiatrist office visit. You say that you are on a fixed income and should be reimbursed for this charge. The Plan denied your request. The Plan says the correct copayment 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 $25 copayment for podiatry services. You have been asked to pay a $25 copayment for a podiatrist office visit. A podiatrist office visit falls within the "Podiatry 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 a podiatrist office visit (99203) on July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe upper partial denture with a flexible base (D5225) provided on February 10, 2020.You asked the Plan to pay forthe dental item. You say that you were not aware that dentures were no longer covered in 2020. You say that it is not fair for your coverage tochange in the middle of your dental work which started when coverage was in effect. You say thatThe Plan denied your request. The Plan says dentures are not listed as a covered service. The Plan says that the Annual Notice of Change (ANOC) for 2020 wassent out August 31, 2019,and September 26, 2019. The Plan says that prosthodontics and maxillofacial services are not covered in 2020.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 among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe upper partial denture with a flexible base (D5225) provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on July 23, 2020.You asked the Planto waive the copayment for a specialist office visit. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $45 copayment for physician/practitioner services/in-network/specialist. You have been asked to pay a $45 copayment for a specialist office visit. A specialist office visit falls within the physician/practitioner services/in-network/specialist 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 specialist office visit provided by a participating provider on July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe panoramic x-ray (D0330) and the initial periapical x-ray (D0220) provided on June 10, 2020.You asked the Plan to pay forthe x-rays. You say that you found the provider through an online list of in network providers. You say that the office failed to verify with your plan that the services would be covered. You say that upon leaving your appointment, you were advised that there was no payment due because the insurance would cover it. You say that you received a bill for $85. You also say that you had to return to the office to get a proposed treatment plan.The Plan denied your request. The Plan says the panoramic x-ray is not listed as a covered service. The Plan says the periapical x-ray is not listed as a covered service either.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceedsMedicare 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 among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe panoramic x-ray (D0330) and the initial periapical x-ray (D0220) provided on June 10, 2020.