Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 7, 2020.
You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim. 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 January 7, 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 for the ambulance services provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 19, 2019, and September 19, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 19, 2019, and September 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the thyroid stimulating hormone (TSH) testing rendered on December 6, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, TSH testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the thyroid stimulating hormone (TSH) testing rendered on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from November 6, 2019, to December 2, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from November 6, 2019, to December 2, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room services (85025, 85610,
12004, 99284) provided December 6, 2019.
You asked the Plan to waive the copayment for the Emergency Room services. You say that the visit on the
date of service in question was a follow up to a previous visit and the copayment should be waived. 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 $90
copayment for Emergency Care.
You have been asked to pay a $90 copayment for the Emergency Room services. The Emergency Room
services falls within the Emergency 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 Emergency Room services (85025, 85610, 12004, 99284) provided December 6, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on November 7, 2019 to January 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physical therapy. You say that you were referred for physical therapy. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that physical therapy services were referred but in-network providers are available 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 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 physical therapy provided on November 7, 2019 to January 28, 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 medical services provided to the enrollee by an out-of-network provider on November 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483, 80307, 80157, 80177, 80201, 80162, 80159, and 80173 provided on October 31, 2019. You asked the Plan to pay for the drug testing. 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 must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes G0483, 80307, 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests were to be performed. The submitted documentation does not itemize what tests were to be included. The documentation submitted indicates a urine specimen was submitted. The billed procedure code requires a blood specimen. Blood specimen collection is by venipuncture, however, the lab requisition states a urine specimen was collected; therefore, codes 80157, 80177, 80201, 80162, 80157, and 80173 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483, 80307, 80157, 80177, 80201, 80162, 80159, and 80173 provided on October 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transport (A0427) and ground mileage (A0425) provided on October 18, 2019 by the provider. You asked the Plan to waive the copayment for the emergency ambulance transport and ground mileage. You say that you should not be responsible for the copayment since you were directed by the plan to go to the emergency room because of an urgent heart issue. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $200 copayment for ambulance services. You have been asked to pay $200 for the emergency ambulance transport and ground mileage. 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 emergency ambulance transport (A0427) and ground mileage (A0425) provided on October 18, 2019 by the provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were unable to get up on your own after you had fallen so you called for assistance. 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 December 2, 2019. 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 for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for crown - full cast high noble metal (D2790) and unspecified adjunctive procedure, by report (D9999) provided on December 9, 2019. You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the plan. 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for crown - full cast high noble metal (D2790) and unspecified adjunctive procedure, by report (D9999) provided on December 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 12, 2019 through November 13, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were in for a knee surgery and were only there overnight. You state you did not know that you would have a copay. The Plan denied your request. The Plan says this was claim was incorrectly processed with a smaller copayment than what the benefits reflect.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from November 12, 2019 through November 13, 2019 provided by an in-network provider. You are asked to pay a $200 copayment for the inpatient hospital care. 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 care from November 12, 2019 through November 13, 2019 provided by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty manual wheelchair.
You asked the Plan to pre-approve a heavy duty manual wheelchair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that heavy duty manual wheelchairs are only covered for certain indications.
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 a heavy duty manual wheelchair. Our reviewer says that the documentation does not support that the requested item is medically reasonable or necessary. Our physician reviewer found the most recent documentation does not reveal an updated weight but a progress note from 2018 indicates a weight over 250 lbs. There is no documentation of severe spasticity. There is no documentation that the patient's mobility deficit interferes with her ability to perform mobility related activities of daily living in the home or is unable to be improved with a walker or cane. The request for a heavy duty manual wheelchair as requested is not medically 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 a heavy duty manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty manual wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology services rendered on August 7, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 81479 is not supported.
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 81479 is unlisted molecular pathology procedure. We find that CPT code 81479 is not supported in the medical record. Specifically, the documentation does not include a complete description of the unlisted code that was billed. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the molecular pathology services rendered on August 7, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous and/or interlaminar device
for the enrollee.
You asked the Plan to pre-approve the device. You say that the insertion of this device is considered medically
necessary by all MACs for patients meeting the approved indications for use. The Plan denied your request.
The Plan says there are no indications for this procedure.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are 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 pre-approve the device. Our reviewer says that the
requested device not considered medically reasonable and necessary in this case. Our physician reviewer found
the device remains experimental for use. More research is needed to show safety and efficacy.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve insertion of an interspinous and/or interlaminar device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested services can be provided by a network provider.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve surgery services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided December 7, 2019 to December 19, 2019.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the correct copayment has been applied to the inpatient hospital care provided.
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 after the yearly deductible is met, enrollees must pay a $225 copayment each day for days 1-6 and $0 for additional days, for each Medicare-covered hospital admission. You have been asked to pay a $1,350 copayment ($225 x 6 days) for inpatient hospital care. 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 inpatient hospital care provided December 7, 2019 to
December 19, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan has to pre-approve additional home health physical therapy services for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee had a stroke, and was just starting to work on standing and transfers. The Plan denied your request. The Plan says that the enrollee is wheelchair bound, and has not made significant progress with therapy. The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 services. Our reviewer says that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee is homebound, as he requires assistance with essential activities of daily living, such as bed mobility and transfers. Skilled therapy services are needed to maintain/improve his level of function. There is no evidence that he is effectively performing his home exercise program with caregiver assistance or that his functional deficits are being mediated through the use of adaptive equipment/ aids. Since having last received physical therapy he has decreased right lower extremity strength and requires more assistance when performing transfers. Physical therapy is indicated for treating his hip and pain through nonpharmacologic means. 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 services have been met. Therefore, we decided that the Plan has to pre-approve additional home health physical therapy services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions of teeth 6, 8, 9, 11, 13, 22, 25, 26, 27 and 28
(D7140) immediate upper denture (D5130) and immediate lower denture (D5140) provided October 31, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing the denial because your top
partial had broken and was causing you to bleed. The Plan denied your request. The Plan says enrollee's must
receive their dental services from an in-network provider. The plan says that non-emergent services require
prior-authorization prior to services being rendered.
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
covered if without a prior authorization or if the services are rendered by an out of network provider.
Therefore, we decided that the Plan does not have to pay for the extractions of teeth 6, 8, 9, 11, 13, 22, 25, 26,
27 and 28 (D7140) immediate upper denture (D5130) and immediate lower denture (D5140) provided October
31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on
January 14, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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. This service is not listed in your EOC as a covered benefit; therefore, it
is not covered. Therefore, we decided that the Plan does not have to pay for bitewings - four radiographic
images (D0274) provided on January 14, 2020 by an out-of-network provider.