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

We decided that the Plan does not have to waive the copayment for the joint injection provided on October 15, 2020.
You asked the Plan to waive the copayment for the joint injection. You say that you did not have surgery. 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 $150 copayment for each Medicare-covered in-network ambulatory surgical center visit. You have been asked to pay a $150 copayment for the joint injection. The joint injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the joint injection is considered a surgical procedure.
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 joint injection provided on October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses (V2025, V2781) purchased from an out-of-network provider on November 19, 2020.
You asked the Plan to pay for the eyeglasses. You say that you believed you would be reimbursed for the glasses. The Plan denied your request. The Plan says they do not cover out-of-network vision services.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are provided in-network by the Plan's contracted vision provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses (V2025, V2781) purchased from an out-of-network provider on November 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 15, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that the ride was uncomfortable and took over an hour. You say that the copayment should be waived. 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 $150 copayment per one-way trip. You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport 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 transport provided on October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular panel testing provided on August 25, 2020.
You asked the Plan to pay for laboratory testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denied coverage for all cardiovascular risk assessment tests/panels except the basic lipid panel.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. While a signed lab requisition was submitted, this requisition did not indicate an order for the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for cardiovascular panel testing provided on August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodic oral evaluations, complete series of intraoral x-rays, prophylaxis, two resin-based composites, three periodontal scalings and root planings, and localized delivery of antimicrobial agents provided from February 10, 2020, to October 19, 2020.
You asked the Plan to pay for the periodic oral evaluations, complete series of intraoral x-rays, prophylaxis, resin-based composites, scalings and planings, and localized delivery of antimicrobial agents. You say that you believe these services should be covered. The Plan denied your request. The Plan says you have already received the maximum amount of coverage allowed.
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 Plan offers a $300 every year for Non-Medicare covered preventive and comprehensive dental services combined. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit while processing your claims for the February 2, 2020, and March 6, 2020 dates of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the two periodic oral evaluations, complete series of intraoral x-rays, prophylaxis, two resin-based composites, three periodontal scalings and root planings, and localized delivery of antimicrobial agents provided from February 10, 2020, to October 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (55650) provided September 11, 2020.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is 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, the CPT Code Manual definition of code 55650 is Excision Procedures on the Seminal Vesicles. We find that CPT code 55650 is not supported in the medical record. Specifically, a prostatectomy was performed and covered. This procedure is part of the prostatectomy and is not separately payable. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (55650) provided September 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 4, 2020.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF care. You say that the enrollee needs physical therapy in order to perform daily functions and take care of himself. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation system (E2300).
You asked the Plan to pre-approve the power seat elevation system. You say that the power seat elevation system is 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 a power seat elevation system is not a covered item. We looked at the file and Medicare rules. Based on this information, we decided that Medicare does not provide coverage for the power seat elevation system. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation system (E2300).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on June 17, 2020.
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 26720 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 26720 is closed treatment of phalangeal shaft fracture,
proximal or middle phalanx, finger or thumb; without manipulation, each.
We find that CPT code 26720 is not supported in the medical record. Specifically, the documentation does not
support that more than one cast, strapping, or splint treatment of multiple closed fractures without manipulation
was performed. 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 surgical services rendered on
June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a clinic visit provided on September 2, 2020.
You asked the Plan to pay for the clinic visit. The Plan denied your request. The Plan says prior authorization was not obtained by the 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 did not pre-approve the clinic visit. 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 a clinic visit provided on September 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation services provided on November 27, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file, and Medicare rules. The records show that the enrollee walked to the stretcher without assistance, and had vitals within normal limits. The documentation support that other means of transport were contraindicated. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation services provided on November 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on September 22, 2020.
You asked the Plan to pay for a pneumatic compression device. You say that the requested item was necessary for the medical safety of the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the requested item is used for a preventive service.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on September 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergent ambulance services.
You asked the Plan to pre-approve non-emergent ambulance services. You say that you feel the services are
appropriate. You state you had a procedure with your hand that prevents you from using a cane to get
downstairs. You state you want the ambulance services to assist you by using the stretcher to get down the
stairs for your appointment. The Plan denied your request. The Plan says there is no documentation that your
condition is such that other means of transportation could endanger the person's health.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of non-emergent ambulance services have not been met. Therefore, we decided that the Plan does not
have to pre-approve non-emergent ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the leg joint.
You asked the Plan to pre-approve MRI of the leg joint. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
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 MRI of the leg joint. Our reviewer says
that the documentation does not support that the requested services are medically reasonable or necessary. Our
physician reviewer found the enrollee has already had an ultrasound of the knee with resultant diagnosis. There
is no documentation that there is a plan to proceed with surgery. The MRI is only needed if surgery is
indicated. Since there is no documentation that the enrollee is willing to proceed with surgery then the MRI is
not needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of MRI of the leg joint have not been met. Therefore, we decided that the Plan
does not have to pre-approve magnetic resonance imaging (MRI) of the leg joint.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the pathology work provided on
November 25, 2020.
You asked the Plan to waive the coinsurance for the pathology work. You say that it does not state anywhere
that there may be additional charges for laboratory work or removal of polyps. 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 laboratory tests.
You have been asked to pay $10.23 which is 20% of the allowed amount for the pathology work. The allowed
amount is $51.15. ($51.15 x 20% = $10.23). The pathology work falls within the "Outpatient diagnostic tests
and therapeutic services and supplies" benefit category. The medical record shows polyps were removed during
the colonoscopy and the specimens were sent to pathology.
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 pathology work provided on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasounds provided on November 12, 2020.
You asked the Plan to waive the copayment for the ultrasounds. You say that this was one procedure, but you were charged twice. You say that the claim should be reprocessed to only charge $160. The Plan denied your request. The Plan says the copayments 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 $160 copayment for each Medicare-covered radiological diagnostic service from an in-network provider. You have been asked to pay a total of $394.22 for the ultrasounds.
Service
Allowed Amount
Standard Copayment
Member Liability
Ultrasound of Aorta
$166.33
$160
$160
Ultrasound of Leg Arteries
$282.82
$160
$160
Ultrasound of Arm and Leg Arteries
$74.22
$160
$74.22
TOTAL:
$394.22
The ultrasounds fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Evidence of Coverage states the copayment applies to each radiological diagnostic 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 ultrasounds provided on November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on
November 12, 2020.
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 hospital outpatient clinic visit. 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 hospital outpatient clinic visit provided on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging (92134) and ophthalmological services (92014) provided January 20, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the imaging and eye exam. You say that a mistake was made, and the services should be reprocessed at in-network rates. The Plan denied your request. The Plan says you became a network provider March 1, 2020, therefore prior services are not covered.
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 at the time of the service. 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 scanning computerized ophthalmic diagnostic imaging (92134) and ophthalmological services (92014) provided January 20, 2021 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on August 24, 2019.
You asked the Plan to pay for the services provided. You say that you did not receive proper notice of the enrollee's benefit determination. The Plan denied your request. The Plan says the claim was received past the allowed 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 the services provided was not filed until November 16, 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 physician services provided on August 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental prophylaxis.
You asked the Plan to pay for the teeth cleaning. You say that you were told by a customer service representative that the supplemental benefit provided three teeth cleanings per year. The Plan denied your request. The Plan says your contract states that you are limited to two cleanings per year.
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 in excess of those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental prophylaxis.