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

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from
January 23, 2021, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary.
The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment. 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 inpatient
mental health care. Our physician reviewer found based upon review the records provided for the admission,
you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of
January 23, 2021, forward as you were not shown to be a danger to yourself or others. You were not showing
any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any
threats the safety. We looked at this physician's review, the file, and Medicare rules. Based on this information,
we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we
decided that the Plan does not have to pre-approve continuation of inpatient mental health care from January
23, 2021, forward.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ano transport ambulance service (A0998) provided on August 26, 2020.You asked the Plan to pay for ano transport ambulance service. You say that the enrollee did not request the ambulance, and therefore, should not be responsible for the payment.The Plan denied your request. The Plan says the service is 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 26, 2020. The ambulance benefit is a transportation benefit. When there is notransport, neither Medicare nor the Plan pays for the services provided. Medicare requires a transport in order to be a covered service, regardless of who calls for the ambulance. The enrollee did not receive a transport and, therefore, the service is notcovered.Therefore, we decided that the Plan does not have to pay for ano transport ambulance service (A0998) provided on August 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided.

You asked the Plan to waive the copayment for the ambulance ride. You say that you believe the rehabilitation hospital should be responsible for the copayment. 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 co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 co payment for Medicare-covered ambulance services per trip. 

You have been asked to pay a $325 copayment for the ambulance ride. The ambulance ride falls 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 ride provided.

Your complaint about the facility should have been watching more closely is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe core build up (D2950) provided on August 31, 2020.You asked the Plan to pay forthe core build up. You say that the root canal should be covered. You also say that there was large distal decay present.The Plan denied your request. The Plan says core build up is only covered in conjunction with a crown. The Plan also says that core build up is not meant to be used as a filling restoration.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage and core build up is listed as a covered service, coverage requires that this service be performed together with a crown. The record does not show that a crown was performed on this date of service.Therefore, we decided that the Plan does not have to pay forthe core build up (D2950) provided on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided on February 18, 2020
by an out of network provider.
You asked the Plan to pay for the ophthalmology services. You say that the provider told you they were in
network. The Plan denied your request. The Plan says you did not request prior authorization for the out of
network 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 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 ophthalmology services provided on February 18, 2020 by an out of network
provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlead wires provided on September 4, 2020.You asked the Plan to pay forlead wires. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the items billed are not payable.The Plan must follow Medicare rules. Medicare rules say that replacement of lead wires (A4557) more often than every twelvemonths would rarely be reasonable and necessary.We looked at the file and Medicare rules. Review of the file shows that lead wires were provided on September 4, 2020. Previously, the enrollee was provided the Transcutaneous electrical nerve stimulation (TENS) unit with lead wires fromJanuary 24, 2020,to February 24, 2020. Twelve months had not passed since the enrollee previously received lead wires. Based on this information, we decided that Medicare rules for coverage of lead wires have not been met.Therefore, we decided that the Plan does not have to pay forlead wires provided on September 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical procedures on the heart (including valves) and great vessels (33340) provided December 10, 2019.You asked the Plan to pay forthe surgical procedure. You say that please review the medical records and pay this claim accordingly.The Plan denied your request. The Plan says missing clinical trial information.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
In this case, we find that CPT code 33340 is not supported in the medical record. Specifically, the clinical trial number was not billed on the claim and per Medicare guidelines is a required item. Based on this information, we decided that Medicare rules for coverage of the surgical procedure have not been met.Therefore, we decided that the Plan does not have to pay forsurgical procedures on the heart (including valves) and great vessels (33340) provided December 10, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extremity veins services provided on
October 14, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the duplex scan of extremity veins 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.
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 duplex scan of extremity veins services
provided on October 14, 2020, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on September 3, 2020.
You asked the Plan to pay for the x-ray 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 separately payable.
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, we have confirmed that code 71045 for the x-ray services has a bundled relationship with code 32555 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on September 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from
January 17, 2020, to January 19, 2020.
You asked the Plan to waive the copayment for inpatient hospital services. You say that you were not informed
of this charge before being released from the hospital. The Plan denied your request. The Plan says you were
charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $180
copayment each day for days 1-7 of a covered inpatient stay during a benefit period for Inpatient Hospital Care.
You have been asked to pay a $360 copayment for two days of a covered inpatient stay during a benefit period
for inpatient hospital services. The inpatient hospital services fall within the Inpatient Hospital Care benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for inpatient hospital services provided from
January 17, 2020, to January 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for gloves (A4927), collagen dressing (A6021, A6023), foam
dressing (A6209, A6211), absorptive dressing (A6252, A6253), wound cleanser (A6260) and gauze (A6402)
provided on March 20, 2020.
You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does
not include a valid physician's order.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid physician order for the supplies provided in this case. Specifically, the
order submitted does not include a signature from the physician. The record shows that the Plan made several
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not
have to pay for gloves (A4927), collagen dressing (A6021, A6023), foam dressing (A6209, A6211), absorptive
dressing (A6252, A6253), wound cleanser (A6260) and gauze (A6402) provided on March 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that thePlan does not have to pay foran orthosis (L4631) provided September 20, 2019.You asked the Plan to pay forthe orthosis. You say that the brace was medically necessary.The Plan denied your request. The Plan says the documentation does not support the billed services.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order. The order does not detail or itemize what type of orthosis was being ordered. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay foran orthosis (L4631) provided September 20, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy provided on April 18, 2018 and May 10, 2018.
You asked the Plan to pay for the occupational therapy. You say that the original claim submission was prior to the timely filing deadline. You say that you are requesting immediate payment. The Plan denied your request. The Plan says the claim was received past the allowed 12-month timeframe.
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 occupational therapy was not filed until August 18, 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 occupational therapy provided on April 18, 2018 and May 10, 2018.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided from September 16, 2020, to September 19, 2020.
You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says that there are no clinical events requiring inpatient care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 inpatient services. Our physician reviewer found that the enrollee presented to the emergency room with complaints of passing blood clots in his urine, despite antibiotics. He underwent a renal ultrasound, which demonstrated no evidence of obstruction. He was started on IV Ceftriaxone and admitted. A Foley catheter was inserted. His condition stabilized and improved with medical therapy. The record showed that at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 inpatient services have been met. Therefore, we decided that the Plan has to pay for inpatient hospital services provided from September 16, 2020, to September 19, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 17, 2020, by an out-of-network provider.You asked the Plan to pay forthe medical services. You say that the claim should be paid.The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider and the services were 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 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 October 17, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvea continuous glucose monitor.You asked the Plan to pre-approvethe requested device. The Plan denied your request. The Plan says that coverage criteria have not been met.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered reasonable and necessary for enrollees with diabetes who meet criteria referenced 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 the requested device. Our physician reviewer found that you have labile blood sugars. You are on multi-dose insulin with a sliding scale with meals. You check your blood sugars 4-5 times a day. The records provided show the coverage criteria have been met. Therefore, the requested monitor is medically reasonable and necessary.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 requested device have been met.Therefore, we decided that the Plan has to pre-approvea continuous glucose monitor.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 the office visit provided on June 2, 2020.
You asked the Plan to waive the copayment for the office visit. You say that the copayment should be waived
for this date of service. 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 $15
copayment for each primary care visit.
You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The record shows the copayment waiver
letter was effective beginning July 1, 2020. Therefore, this visit was not eligible for the waiver.
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 office visit provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99214) provided on September 10, 2020.
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 services were not emergent. There were network providers
available.
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 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 physician services (99214) provided on September 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan you had on June 16, 2020.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the copayment.
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 $150 copayment for each CT scan. Review of the file show that you had a CT scan on June 16, 2020. Per your contract with the Plan, there is a $150 copayment for CT scans. However, the Medicare allowed amount for these services was $113.66. Given that the allowed amount was less than the $150 copayment, you have been asked to pay $113.66 for these services. 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 CT scan you had on June 16, 2020.