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

We decided that the Plan does not have to pay for prophylaxis - adult (D1110), comprehensive oral evaluation - new or established patient (D0150), bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided on February 13, 2020 by an out-of-network provider. You asked the Plan to pay for the dental services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits. The Plan states they reviewed your call history, and found a call from February 11, 2020, in which you called regarding your vision and dental benefits. The Plan states while you were given information about your dental benefits, you were never given any information about dental providers.
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. For code D1110, the provider billed the plan $79.00. The allowed amount for the service is $43.00, and the plan paid $43.00. You are responsible for all fees in excess of the allowed amount, $36.00 ($79 - $43). For code D0150, the provider billed the plan $68.00. The allowed amount for the service is $29.00, and the plan paid $29.00. You are responsible for all fees in excess of the allowed amount, $39.00 ($68 - $29). For code D0274, the provider billed the plan $44.00. The allowed amount for the service is $28.00, and the plan paid $28.00. You are responsible for all fees in excess of the allowed amount, $16.00 ($44 - $28). For code D0220, the provider billed the plan $26.00. The allowed amount for the service is $11.00, and the plan paid $11.00. You are responsible for all fees in excess of the allowed amount, $15.00 ($26 - $11). For code D0230, the provider billed the plan $26.00. The allowed amount for the service is $9.00, and the plan paid $9.00. You are responsible for all fees in excess of the allowed amount, $17.00 ($26 - $9). The $123.00 which was assessed as your out-of-network liability is correct. Therefore, we decided that the Plan does not have to pay for prophylaxis - adult (D1110), comprehensive oral evaluation - new or established patient (D0150), bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided on February 13, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pacemaker evaluation provided on January 13, 2020.
You asked the Plan to waive the copayment for the pacemaker evaluation. You say that you have never had to pay for this service before. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment per visit to a specialist. You have been asked to pay a $35 copayment for the pacemaker evaluation. The pacemaker evaluation falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the pacemaker evaluation is a physician service.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the pacemaker evaluation provided on January 13, 2020.
Our decision is only about the 2020 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 16, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says there is no
network deficiency for the services, and alternate network providers were found.
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 services at
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 for the medical services provided on December 16, 2019 by an out of
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia under Medicare Part B.
You asked the Plan to pre-approve Prolia under Medicare Part B. You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not covered under Medicare Part B but they will approve it under the enrollee's Medicare Part D benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia under Medicare Part B.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for thyroid imaging services provided on February 20, 2020.
You asked the Plan to pay for the thyroid imaging services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services 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 thyroid imaging services provided on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the office visit provided on November 18, 2019.
You asked the Plan to reduce the coinsurance for the office visit. You say that you were not aware the provider was out-of-network. You say you would like the claim processed as in-network. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% of the Medicare-allowed amount for each primary care provider visit or each specialist visit for Medicare-covered services. You have been asked to pay $44.69 which is 50% of the allowed amount for the office visit. The allowed amount is $89.38. ($89.38 x 50% = $44.69). The office visit falls within the "Physician/Practitioner services, including doctor's office visits" category. The record shows the provider is out-of-network.
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 reduce the coinsurance for the office visit provided on November 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 19, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on November 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive periodontal evaluation (D0180) periodontal scaling and root planing (D4341)  intraoral -periapical each additional x-ray (D0230) provided September 30, 2019 to October 28, 2019.You asked the Plan to pay forthe dental services. You say that you are appealing because you were referred to this provider and this was a medically necessary emergency procedure.The Plan denied your request. The Plan says D0180 and D4341 are not covered under the plan benefits. D0230 exceeds the benefit limit of 4 in a 12 month period.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 allows 4 intraoralperiapical x-rays every 12 months. The records show that 4 x-rays (D0220 and D0230) were paid for date of service 09/30/2019. The other 2 exceeds the benefit limit.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 forcomprehensive periodontal evaluation (D0180) periodontal scaling and root planing (D4341)  intraoral -periapical each additional x-ray (D0230) provided September 30, 2019 to October 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided
November 11 - December 10, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF
services. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of
coverage were not 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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily
basis and does 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 services have not been met. Therefore, we decided that the Plan does
not have to pay for the skilled nursing facility (SNF) services provided November 11 - December 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered medications provided from March 13, 2020 to March 16, 2020.You asked the Plan to waive the copayment for the self-administered medications. You say that the Plan should pay for the drugs.The Plan denied your request. The Plan says the drugs are not covered under your Medicare Part B 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 pay for the self-administered medications provided from March 13, 2020 to March 16, 2020.Benefits for the self-administered medications may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx testing services provided on December 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for the testing services. You say that the testing is a covered Medicare benefit.The Plan denied your request. The Plan says there is no authorization on file for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services 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 forthe DecisionDx testing services provided on December 9, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on December 10, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation does not include a valid physician order, or medical records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more drug classes. We find that CPT code G0483 is not supported in medical records. There were insufficient records that show the tests were needed to identify specific substances that were inadequately detected by a presumptive drug test. There is no evidence that shows the test was individualized to identify 22 or more specific non-prescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided on January 28, 2020 by an out-of-network provider. You asked the Plan to pay for the dental services. You say that you have gone to this provider since 1969 and when you signed up with the plan you were told that your dentist was in your plan. The Plan denied your request. The Plan says you do not have out-of-network benefits. The Plan states there are no calls from you prior to March 18, 2020. 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. Review of the file show that you received the dental services on January 28, 2020 by an out-of-network provider. Your EOC states, supplemental preventive and supplemental comprehensive dental benefits must be obtained from a provider in your dental vendor network. Services obtained from vendors outside this network are not covered. 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 periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided on January 28, 2020 by an out-of-network
provider.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance service (A0428) and the ground mileage (A0425)
provided on January 3, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says that the claim was submitted outside the filing timeframe.
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 rules also say that Plan must identify payers that are primary to Medicare, identify the amounts
payable by the primary payer, and coordinate benefits to Medicare enrollees with the benefits of the primary
payer.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the ambulance services have been met. Specifically, the Plan offered multiple denial rationales
within the record that are not substantiated. The Plan stated that the claim was submitted untimely, but the
evidence indicates that the claim was submitted timely (multiple times). The Plan states that an Explanation of
Benefits is needed from a primary payer, but the Plan has not identified who the primary payer is or
coordinated benefits. Lastly, the Plan states that the enrollee was on Hospice. The record does not contain
official documentation to show that the enrollee was enrolled on Hospice for the date of service at issue. The
Plan denial is not substantiated in this case and we must find in your favor. Therefore, we decided that the Plan
has to pay for the ambulance service (A0428) and the ground mileage (A0425) provided on January 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR, outpatient rehabilitation). 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 the clinical documentation provided supports the requested for LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care does not require transfer to an LTACH. 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 is currently undergoing treatment at an acute care hospital (ACH), having been admitted with a vertebral fracture after a fall. The enrollee underwent surgery to repair the fracture. The enrollee is receiving concomitant care for his chronic liver disease and chronic kidney disease. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided from October 4, 2019 to November 1, 2019.
You asked the Plan to waive the copayments for the specialist office visits. You say that you cannot afford the copayments. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment. for each specialist visit for Medicare-covered benefits. You have been asked to pay a $45 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" 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 copayments for the specialist office visits provided from October 4, 2019 to November 1, 2019.