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

We decided that the Plan does not have to pay for laboratory testing provided on December 14, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for lab test. 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 this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.
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 laboratory testing provided on December 14, 2020 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the care and services required by this enrollee exceeds the clinical capabilities of all lower levels of care. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with toxic encephalopathy secondary to polymicrobial sepsis due to an infected breast implant at a previous mastectomy site. At this time, the enrollee is receiving two antibiotics and is not on mechanical ventilation. The wound has been closed. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Budesonide inhalation solution (J7626) provided on August 24, 2020, by an out-of-network provider.
You asked the Plan to pay for Budesonide. You say that you have been getting your medications from the same provider for years with no problem. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
The Plan must follow Medicare rules. The rules say that, except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for Budesonide inhalation solution (J7626) provided on August 24, 2020, by an out-of-network provider.
Your complaint about receiving erroneous or incomplete information from the provider about the provider's network status 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99214) provided on December 8, 2020.
You asked the Plan to waive the copayment for an office visit. You say that your visits with the provider have been for screening of glaucoma. You also say you have type 2 diabetes. You do not think you should pay a copayment as the EOC states you pay a $0 copayment per visit for glaucoma and diabetic screening. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $35 copayment per visit to an ophthalmologist or optometrist for Medicare-covered vision care. Your contract with the Plan also clearly says that they will cover one glaucoma screening each year for people who are high risk of glaucoma and they will also cover one screening for diabetic retinopathy for people with diabetes. You have been asked to pay a $35 copayment for an office visit. The records show that you had a follow up visit for borderline glaucoma. The records also show that you had a previous screening on June 9, 2020. The EOC confirms that you are allowed one screening per year; therefore, $35 is the required copayment 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 an office visit with a specialist (99214) provided on December 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support,
non-emergency transport (A0428) and ground mileage, per statute mile (A0425) provided October 16, 2020,
and December 4, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that you received
authorization for the services which did not indicate that you would be responsible for a copayment. The Plan
denied your request. The Plan says the copayments were 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 $200
copayment for each one-way ambulance trip. You have been asked to pay a total of $400 ($200 copayment x 2 trips = $400) for the ambulance services. This
service 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 service, basic life support, non-emergency transport (A0428) and ground mileage, per statute
mile (A0425) provided October 16, 2020, and December 4, 2020.
Your complaint about the Plan not including the copayment amount on your authorization notice 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (J3490, J1955) provided on December 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We asked our coding 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 services Our reviewer says that the records provided do not support 5 units of code J3490 and 4 units of code J1955. Our coding reviewer found that the submitted documentation does not confirm 4 units billed for CPT J3490. The documentation states "a pre-filled syringe containing the nutri-pharmaceutical blend/mix with a 30 gauge 0.5 inch needle was inserted and observed tracking to the correct position as defined in procedure anatomical location above". This confirms 1 unit was given. For CPT J1955, it cannot be confirmed that Levocarnitine was given on the date of service in question. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (J3490, J1955) provided on December 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on January 23, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport (A0998). You say that you were 
experiencing headaches after a new furnace was installed and you called emergency services. You say that you 
refused transport and believe you should not be financially liable since you did not call for an ambulance to 
come to your home. The Plan denied your request. The Plan says ambulance service is only payable when 
transported to a hospital. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
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 ambulance response and treatment, no 
transport. Our reviewer says that ambulance response and treatment, no transport does not meet Medicare 
coverage criteria. Our physician reviewer found that you had a mild headache for the past few weeks prior to the services and you believed that you might have CO poisoning. Emergency Medical Services (EMS) arrived, 
and you were alert and not in any distress. No odors were present in your home. Your vitals and exam were 
normal including oxygen saturation of 95-98% on room air. You were offered transport to the emergency 
department, but you refused. Based on the provided documentation, you do not meet the CMS "treat in place" 
COVID-19 protocols for medically necessary ambulance services as you refused transport and you were stable. 
 
The ambulance company did not provide transport services on January 23, 2021. 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 ambulance response and treatment, no transport 
(A0998) provided on January 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) provided February 23, 2021.
You asked the Plan to waive the copayment for the ambulance transport. You say that you did not realize the copayment would be so high and would like it reduced or waived. The Plan denied your request. The Plan says the copayment was 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 $325 copayment per trip for Medicare-covered ambulance services. You have been asked to pay a $325 copayment for the ambulance transport. This service 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 service, basic life support, non-emergency transport (A0428) provided February 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
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 pre-approve inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The enrollee is scheduled for a total knee arthroplasty. The record does not indicate that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights based upon complex medical factors documented in the medical record. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital services. 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 hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) provided February 17, 2021.
You asked the Plan to waive the coinsurance for the automatic external defibrillator. You say that you were informed by a nurse that you would be covered for 3 months and you would not have to pay anything and now you received a bill you were not expecting. The Plan denied your request. The Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage.
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 30% coinsurance for each out of network Medicare covered durable medical equipment item. You have been asked to pay $879.44 (2,931.45 x 30%) for the automatic external defibrillator. The automatic external defibrillator falls within the Durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) provided February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for/pay an additional amount for a teeth cleaning (D1110), fillings (D2331, D2332 x2, D2392), a limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0220) provided from March 3, 2021, through March 4, 2021.
You asked the Plan to pay for/pay an additional amount for a teeth cleaning, fillings, a limited oral evaluation, and an intraoral periapical radiographic image. You say that the services were necessary. The Plan denied your request. The Plan says the fillings are a covered benefit, but you have exceeded the frequency limit of two per calendar year. The limited oral evaluation, and intraoral periapical radiographic image are not covered benefits. The provider was paid at the Medicare allowed rate for the teeth cleaning and two fillings therefore no additional payment can be made.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a teeth cleaning, fillings, a limited oral evaluation, and an intraoral periapical radiographic image have not been met. Specifically, the record shows that you had exceeded the frequency limit for fillings for the calendar year. The limited oral evaluation, and intraoral periapical radiographic image are not covered benefits. Additionally, the allowed amount for the teeth cleaning and two fillings for an out-of-network provider were paid by the plan. Therefore, we decided that the Plan does not have to pay for/pay an additional amount for a teeth cleaning (D1110), fillings (D2331, D2332 x2, D2392), a limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0220) provided from March 3, 2021, through March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and bone
replacement graft (D7953) provided on April 21, 2021.
You asked the Plan to pay for the dental services. You say that these services were necessary to prepare your
mouth for future dental implants and should be covered. The Plan denied your request. The Plan says these
services are not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
guided tissue regeneration (D4266) and bone replacement graft (D7953) provided on April 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you were hospitalized for brain surgery and you are not in a condition to go home and care for yourself on your own. The Plan denied your request. The Plan says the stay is not medically necessary.
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. You were admitted for seizures and had bifrontal craniotomy to remove a brain tumor. Medical problems are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on April 13, 2021.
You asked the Plan to pay for an eye refraction. You say that you are borderline diabetic, and you need to continue to have eye exams. The Plan denied your request. The Plan says the service is not a covered benefit.
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 it is performed as part of a routine screening or after a cataract surgery with the correct diagnosis. We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on April 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted after a one day stay at skilled nursing facility due to worsening infected coccygeal wound and infected percutaneous endoscopic gastrostomy (PEG) tube. The enrollee has poor nutritional status, delaying surgical intervention. The enrollee continues to receive acute care services, and these have not been denied.
The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.