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

We decided that the Plan does not have to pay for the shoulder x-ray (73030) provided on August 13, 2020.

You asked the Plan to pay for the shoulder x-ray. You say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the shoulder x-ray (73030) provided on August 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 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 patient does not require treatment by multiple therapies and there are no complex nursing or rehabilitation 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 IRF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Prolia 60 mg/ml subcutaneous injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy must be tried.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no sufficient clinical rationale to approve a step therapy exception. An adverse gastrointestinal effect with an oral bisphosphonate does not preclude a trial with an intravenously administered bisphosphonate as side effects cannot reliably be extrapolated from one formulation to another. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Prolia 60 mg/ml subcutaneous injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccine (90750) provided January 25, 2021.

You asked the Plan to pay for the vaccine. You say that the shingles vaccine should be covered. The Plan
denied your request. The Plan says this vaccine is covered under the Part D benefit and is not eligible for
coverage under the Part B medical benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The
Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the vaccine.
Therefore, we decided that the Plan does not have to pay for a shingles vaccine (90750) provided January 25,
2021.

Benefits for the vaccine 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 lab services (81404, 81479) provided January 12, 2021.
You asked the Plan to pay for the lab services. You say that the genetic testing was medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all Cardiovascular risk assessment panels except the basic lipid panel, for symptomatic patients with suspected or documented Cardiovascular disease.
We looked at the file and Medicare rules. The cardiovascular risk assessment panel is not covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81404, 81479) provided January 12, 2021.
Appeal type: Other
Decision: Favorable

We decided that the Plan has to pay for hospital services provided from June 11, 2020, through June 13, 2020.
You asked the Plan to pay for the hospital services. You say that you received two claims in the mail and would like to get them resolved. The Plan denied your request. The Plan says that the Plan did not render a decision within the allotted timeframe.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the hospital services by a contract hospital. The file does not show that the Plan provided notice that the hospital services would not be covered prior to the services being provided. Under Medicare rules, this means the hospital services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for hospital services provided from June 11, 2020, through June 13, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and the Part B drug provided on October 20, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit and Part B drug. You say that the service was medically necessary, and you were not given enough time to obtain authorization due to wrong insurance information. The Plan denied your request. The Plan says no prior authorization was 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 the office visit and the Part B drug provided on October 20, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support,
emergency transport (A0429) provided March 7, 2020.

You asked the Plan to waive the copayment for the emergency ambulance service. You say that this charge was
part of an emergency room visit and you would like the Plan to pay this bill. The Plan denied your request. The
Plan says ambulance services are a separate benefit from emergency room services and the copayment has been
applied 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 $240 for
Ambulance services.

You have been asked to pay $240 for the emergency ambulance service. The ambulance services are a separate
benefit from emergency room services. Emergency ambulance services fall 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 service, basic life
support, emergency transport (A0429) provided March 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from December 8, 2020, to December 31, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the additional copayment because the enrollee already paid a $500 copayment and was transferred to reduce the overall cost. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $100 copayment per day for days 1-5 for inpatient hospital care. 

The enrollee had an inpatient stay from December 8, 2020, to December 31, 2020. This is considered a new inpatient hospital stay. Therefore, the enrollee is responsible to pay a $100 copayment for days 1-5 (December 8, 2020, to December 12, 2020). $100 (copayment) x 5 (inpatient days) = $500. 

The enrollee has been asked to pay the total copayment amount of $500 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from December 8, 2020, to December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames (V2020), sphere, bifocal, plano to plus or minus 4.00D, per lens (V2200), and progressive lenses (V2781) provided February 19, 2021.

You asked the Plan to pay for the frames and lenses. You say that the new lenses were medically necessary to help with blurriness and double vision. The Plan denied your request. The Plan says your routine eye wear allowance was previously used, and you are responsible for the costs of the current eye wear.

Medicare generally does not cover routine vision and eye wear services. However, the Plan offers a routine vision and eye wear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine eye wear up to a $175 vision allowance every rolling calendar year.

We looked at the file and the Plan's rules. The Plan provided documentation showing that routine eye wear was previously covered up to your vision allowance on June 4, 2020. Based on this information, we decided that the Plan does not have to pay for the frames (V2020), sphere, bifocal,  to plus or minus 4.00D, per lens (V2200), and progressive lenses (V2781) provided February 19, 2021.plano
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on February 3, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the rest home visit. You say that the services were medically necessary. You say the enrollee could not choose an in-network dermatologist since no other provider was allowed into the facility during the Covid-19 pandemic. The Plan denied your request. The Plan says no prior authorization was 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 the rest home visit provided on February 3, 2021 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427, A0425) received February 6, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford the copayment. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $350 copayment for Ambulance Services. You have been asked to pay a $350 copayment for the ambulance transportation. The ambulance transportation 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 transportation (A0427, A0425) received February 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided by an out-of-network provider on November 18, 2020.

You asked the Plan to pay for the vision services. You say that the patient has been under the care of the practice for many years. You say that the medical records support the claim and the claim should be reprocessed for payment. The Plan denied your request. The Plan says prior authorization was required but 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 the vision services provided by an out-of-network provider on November 18, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425), and the basic life support, emergency transport (A0429) provided on November 27, 2020.

You asked the Plan to pay for the transportation 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 enrollee'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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425), and the basic life support, emergency transport (A0429) provided on November 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on January 5, 2021.

You asked the Plan to waive the copayment for the arthrocentesis. You say that the authorization was on file for this visit, and you should not be responsible. The Plan denied your request. The Plan says the copayment applied 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 $250 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.

You have been asked to pay a $250 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The arthrocentesis is considered a surgical 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 arthrocentesis provided on January 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bypass operation of stomach using an endoscope (43644).

You asked the Plan to pre-approve the bypass operation of stomach using an endoscope. You say that the enrollee's condition would benefit from the requested surgery. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees who have: 

(1) a body mass index (BMI) of greater than or equal to 35; 

(2) at least one co-morbidity related to obesity; and 

(3) been unsuccessful with medical treatment for obesity.

We looked at the file and Medicare rules. In this case, the medical documentation indicates that your BMI is not greater than or equal to 35. Based on this information, we decided that Medicare rules for coverage of the bypass operation of stomach using an endoscope have not been met. Therefore, we decided that the Plan does not have to pre-approve the bypass operation of stomach using an endoscope (43644).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and two additional intraoral periapical x-rays provided on February 9, 2021.

You asked the Plan to pay for the intraoral periapical x-rays. You say that these x-rays were necessary for your tooth to be looked at. The Plan denied your request. The Plan says these services are not covered.

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 for the first intraoral periapical x-ray and two additional intraoral periapical x-rays provided on February 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy provided on February 22, 2021.

You asked the Plan to waive the coinsurance for the chemotherapy. You say that you would like to appeal the charge due to Medicare benefit changes. 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 outpatient chemotherapy, Part B drugs, and other outpatient services.

You have been asked to pay $490.38 which is 20% of the allowed amount for the chemotherapy. The allowed amount is $2,451.93. ($2,451.93 x 20% = $490.38). The chemotherapy falls within the "Outpatient hospital 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 coinsurance for the chemotherapy provided on February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays
(D0274), cleaning (D1110) and fluoride application (D1208) provided on February 17, 2021, by an out-of-network
provider.

You asked the Plan to pay for the dental services. You say that the front desk at the provider's office told you
they accept your insurance. The Plan denied your request. The Plan says this provider is not in the Plan's dental
network. Services provided out-of-network will not be covered.

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, items or services received outside the
Plan's dental network are not covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), cleaning (D1110) and fluoride
application (D1208) provided on February 17, 2021, by an out-of-network provider.