Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe x-ray, the echocardiogram, and the inpatient hospital stay provided from July 6, 2020, to July 21, 2020.You asked the Plan to waive the copayments forthe x-ray, the echocardiogram, and the inpatient stay. You say that you already paid a total of $99 for the services. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $14 copayment for each Medicare-covered standard x-ray service, a $90 copayment each Medicare-covered radiological diagnostic service, not including x-rays performed in a physician's office or at a freestanding facility (such as a radiology center or medical clinic), and a $295 copayment for each day for days 1 to 4 for Medicare-covered hospital care. You have been asked to pay a $14 copayment for the x-ray, a $90 copayment for the echocardiogram, and a $295 copayment for the inpatient stay. The x-ray and the echocardiogram fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. 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 youenrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments forthe x-ray, the echocardiogram, and the inpatient hospital stay provided from July 6, 2020, to July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe intraoral x-ray imaging (D0210), pre-diagnostic testing (D0431), core buildup services (D2950) and porcelain/ceramic crowns (D2740) provided on September 24, 2020 and October 13, 2020.You asked the Plan to pay forthe dental services. You say that this provider was listed as in-network on the Plan's website and these services should be covered.The Plan denied your request. The Plan says these servicesare not covered by Medicare or by the Plan's supplemental dental benefit. Please note that the Plan has agreed to cover the cleaning, oral evaluationand composite restoration,but the intraoral x-ray,pre-diagnostic testing, core buildup services and crowns are not covered under any circumstances.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 intraoral x-ray imaging (D0210), pre-diagnostic testing (D0431), core buildup services (D2950) and porcelain/ceramic crowns (D2740) provided on September 24, 2020 and October 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from September 24, 2020, to October 23, 2020.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.The Plan must follow Medicare rules. The rules say that Medicare pays forcare in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require dailyskilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services havenot been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from September 24, 2020, to October 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120).
You asked the Plan to pre-approve a fixed partial denture sectioning. You say that this is a medically necessary service that affects how you can chew and digest your food and impacts your self-esteem. The Plan denied your request. The Plan says this service is not covered under Medicare or your supplemental dental benefit.
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 pre-approve a fixed partial denture sectioning (D9120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator provided on
August 27, 2020.
You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that before you enrolled in
this Plan, you were told you do not have to pay a copayment. The Plan denied your request. The Plan says you
have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare-covered item.
You have been asked to pay $20.18 which is 20% of the allowed amount for the oxygen concentrator. The
allowed amount is $100.89. ($100.89 x 20% = $20.18). The oxygen concentrator falls within the "Durable
medical equipment (DME) and related supplies" 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
coinsurance for the oxygen concentrator provided on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on September 14, 2020.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says the orthoses are not supported in the medical records received.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 lumbar-sacral orthosis (L0650). Our reviewer says that the orthosis is not medically necessary. Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back.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 lumbar-sacral orthosis (L0650) have not been met.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on September 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 4, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that the Tempus XF test is not a covered benefit. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fornursing facility care (99309) provided on November 10, 2020.You asked the Plan to pay fornursing facility care. You say that this is separate from all other charges.The Plan denied your request. The Plan says this is mutually exclusive to another service performed by the same provider on the same date of service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Many procedure codes cannot be reported together because they are mutually exclusive of each other. Mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same patient encounter. We find that CPT code 99309 is not supported in the medical record. Specifically, this code is mutually exclusive with G0438, which was billed for the same date of service by the same provider. Based on this information, we decided that Medicare rules for coverage of nursing facility care have not been met.Therefore, we decided that the Plan does nothave to pay fornursing facility care (99309) provided on November 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services, the subsequent nursing facility care, and the hospital discharge day management provided from December 12, 2019, to December 17, 2019.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee'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. The Plan also says 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on December 11, 2019. The services in question were provided before the end of that month. Additionally, the record shows that the enrollee re-enrolled in Hospice benefits on December 17, 2019. Therefore, we decided that the Plan does not have to pay for the critical care services, the subsequent nursing facility care, and the hospital discharge day management provided from December 12, 2019, to December 17, 201
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for rest home visit provided on November 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for rest home visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider or facility.
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 rest home visit provided on November 23, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Medicare Part B drug and the copayment for the ultrasound provided on September 9, 2020.
You asked the Plan to waive the coinsurance for the Medicare Part B drug and copayment for the ultrasound. You say that you only have a $50 physician copayment. The Plan denied your request. The Plan says you have a coinsurance for drugs and a copayment for ultrasounds.
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 20% coinsurance for Medicare Part B prescription drugs and a $60 copayment for ultrasounds. You have been asked to pay 20% coinsurance for the Medicare Part B drug and a $60 copayment for the ultrasound. The drug falls within the Medicare Part B prescription drugs benefit category. The ultrasound falls within the Outpatient Diagnostic Test 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 coinsurance for the Medicare Part B drug and the copayment for the ultrasound provided on September 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the flow cytometry provided on August 29, 2020.
You asked the Plan to pay for the flow cytometry. The Plan denied your request. The Plan says this was not medically necessary.
The Plan follows Medicare rules. Medicare rules say that flow cytometry is covered for the indications established in the applicable LCD. 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 flow cytometry. Our reviewer says that the requested flow cytometry was not medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of lymphoproliferative disorder or acute leukemia. The requested flow cytometry was not medically reasonable or necessary according to the coverage indications established in the applicable LCD. 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 flow cytometry have not been met. Therefore, we decided that the Plan does not have to pay for the flow cytometry provided on August 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider on August 13, 2020.
You asked the Plan to pay for nursing facility care. You say that medical records and proof of timely filing are attached for retro authorization. The Plan denied your request. The Plan says prior authorization was not obtained.
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 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 nursing facility care provided by an out-of-network provider on August 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the venipuncture provided on September 21, 2020.
You asked the Plan to waive the copayment for the venipuncture. You say that the venipuncture should be fully paid for every time. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that an office visit or outpatient facility copayment may apply for additional services including venipuncture. The health plan contract says that enrollees must pay a $20 copayment for each PCP type provider office visit, virtual visit, or remote evaluation. You have been asked to pay $5.88, which is less than the standard $20 copayment for the venipuncture. The venipuncture falls 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 copayment for the venipuncture provided on September 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves (L1833, L2397).
You asked the Plan to pay for the knee orthoses and suspension sleeves. You say that the requested items were medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.
The Plan follows Medicare rules. Medicare rules say that the requested knee orthosis is subject to the coverage criteria listed in the Medicare rules section. 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 knee orthoses and suspension sleeves. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. 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 knee orthoses and suspension sleeves have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves (L1833, L2397).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services provided on March 22, 2019.
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 the injection services was not filed until October 15, 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 injection services provided on March 22, 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.
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 with Methicillin-resistant Staphylococcus aureus (MSRSA) bacteremia and osteomyelitis with paraspinal abscess. The enrollee underwent T7-L2 posterior fusion and T9-10 debridement/corpectomy. 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.