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

We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided by a participating provider on April 16, 2021.
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that this should be covered fully. The Plan denied your request. The Plan says the correct copayment has been 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 $45 copayment for outpatient diagnostic tests/in-network/ultrasound. You have been asked to pay a $45 copayment for a diagnostic ultrasound. The ultrasound that was provided was diagnostic in nature; therefore, the correct copayment has been applied. A diagnostic ultrasound falls within the outpatient diagnostic tests/in-network/ultrasound 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 a diagnostic ultrasound provided by a participating provider on April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 21, 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 drug testing rendered on December 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care for left knee joint replacement surgery (CPT code 27447), for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The Plan states the planned procedure listed under CPT code 27447 is not listed on the Centers for Medicare and Medicaid Services (CMS) Inpatient Only List. The Plan states the procedure is currently approved as an ambulatory procedure and there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The Plan states if the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not show that at the admitting physician reasonably expects that the enrollee's necessary hospital care will span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care for left knee joint replacement surgery (CPT code 27447), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental gradient pressure pneumatic appliance (E0673) provided January 26, 2021.
You asked the Plan to pay for the pneumatic compression device and appliance. You say that the equipment was prescribed by the doctor and issued to the enrollee for use during their surgery. You are not contracted with the facility or the prescribing physician and do not receive payment from either provider. The Plan denied your request. The Plan says the pneumatic compression device and/ or supplies is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting. We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental gradient pressure pneumatic appliance (E0673) provided January 26, 2021.
You asked the Plan to pay for the pneumatic compression device and appliance. You say that the equipment was prescribed by the doctor and issued to the enrollee for use during their surgery. You are not contracted with the facility or the prescribing physician and do not receive payment from either provider. The Plan denied your request. The Plan says the pneumatic compression device and/ or supplies is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on November 23, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on November 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting additional routine transportation trips. The Plan denied your request. The Plan says you exhausted your benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. This request exceeds your benefit limit. Your 2021 EOC states up to 48 one-way trips are covered per calendar year (limited to ground transportation only). Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 15, 2021.
You asked the Plan to pay for the limited oral evaluation (D0140). You say that the bill is a mistake and should be rectified. The Plan denied your request. The Plan says the service is only covered once per plan 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, you also have a maximum benefit of one limited oral evaluation every plan year. The Plan paid for a limited oral evaluation provided on January 20, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 skilled nursing visits (G0299, G0300), 12 physical therapy visits (G0151), and 12 occupational therapy visits (G0152).
You asked the Plan to pre-approve the home health services. You say that the services are medically necessary. The Plan denied your request. The Plan says the provided documentation does not indicate that the enrollee is homebound.
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 home health services. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the provided documentation does not clearly indicate whether the enrollee is homebound. The reviewer found that the enrollee does not have documented skilled nursing needs. The reviewer found that the enrollee does not have documented skilled therapy needs. Therefore, the reviewer found that the requested home health services are not medically necessary and reasonable. 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 home health services have not been met. Specifically, the enrollee does not require any skilled services. Therefore, we decided that the Plan does not have to pre-approve 12 skilled nursing visits (G0299, G0300), 12 physical therapy visits (G0151), and 12 occupational therapy visits (G0152).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D3221) provided to you on April 12, 2021.

You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says this is not a covered service.

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 services are not among those covered under this benefit. The Plan covers only those dental services for which the codes are listed in the Evidence of Coverage. Dental code D3221 is not listed, and therefore, is not covered. Therefore, we decided that the Plan does not have to pay for the dental services (D3221) provided to you on April 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for diabetic monitoring supplies provided by a
participating provider on January 22, 2021.
You asked the Plan to waive the coinsurance for diabetic monitoring supplies. You say that you did not ask for
any medical supplies. The Plan denied your request. The Plan says the correct coinsurance has been 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 20%
coinsurance for diabetes self-management training/in-network/diabetic monitoring supplies/diabetic supplier. You have been asked to pay a 20% coinsurance of the allowed amount for diabetic monitoring supplies. The
total allowed amount is $402.05. You are being asked to pay $80.39 which is less than your 20% coinsurance
amount of $80.41 ($402.05x 20% = $80.41). Diabetic monitoring supplies falls within the diabetes selfmanagement
training/in-network/diabetic monitoring supplies/diabetic supplier 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 diabetic monitoring supplies provided by a participating provider on
January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on March 30, 2021.
You asked the Plan to waive the copayment for specialist services. You say that this was just to have test results read. The Plan denied your request. The Plan says the correct copayment has been 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 $35 copayment for physician services/specialty. You have been asked to pay a $35 copayment for specialist services. The correct copayment has been applied to the services that were provided. Specialist services fall within the physician services/specialty 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 specialist services provided by a participating provider on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), resin-based composite - one surface, posterior (D2391), intraoral - periapical first radiographic image (D0220), and endodontic therapy, molar tooth (excluding final restoration) (D3330) provided March 29, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the limited oral exam, resin-based composite filling, intraoral x-ray and root canal. You say that you were told the root canal would be covered at 50%. The Plan denied your request. The Plan says these services are not covered because they were rendered by an OON provider.
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. The Plan covers the limited oral exam, resin-based composite filling, intraoral x-ray and root canal when received from a participating provider
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the limited oral exam, resin-based composite filling, intraoral x-ray and root canal have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), resin-based composite - one surface, posterior (D2391), intraoral - periapical first radiographic image (D0220), and endodontic therapy, molar tooth (excluding final restoration) (D3330) provided March 29, 2021, by an out-of-network (OON) provider.
Your complaint about potentially receiving misinformation from a plan representative or provider 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 ophthalmology services provided on March 2, 2021, by an out-of-network provider.
You asked the Plan to pay for the ophthalmology services. You say that the doctor is not responsible to obtain authorization. The Plan denied your request. The Plan says authorization was not requested or obtained prior to services being rendered.
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the ophthalmology services provided on March 2, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2331) for tooth #11 provided on May 5, 2021.
You asked the Plan to pay for the dental service. You say that the provider that you saw is listed as in network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services performed by an out of network provider 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, dental services performed out of network are not covered among this benefit. Therefore, we decided that the Plan does not have to pay for the filling (D2331) for tooth #11 provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (S0621), eyeglass frames (V2025) and progressive lenses (V2781) provided on March 31, 2021.
You asked the Plan to pay for an eye exam, eyeglass frames and progressive lenses. You say that you do not agree with the denial on this claim. You also say that you do not have the option to wait weeks to get new glasses. You would like the claims to be reprocessed and paid. The Plan denied your request. The Plan says services will only be covered when they are received from a provider in the specified vision network.
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 obtained through one of the Plan's routine vision service providers. We looked at the file and the Plan's rules. The services at issue are not covered if performed by a provider that is not part of the Plan's routine vision network. The provider at issue is not one of the Plan's in-network providers. Based on this information, we decided that the Plan's rules for coverage of an eye exam, eyeglass frames and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam (S0621), eyeglass frames (V2025) and progressive lenses (V2781) provided on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on April 19, 2021 by an OON
provider.
You asked the Plan to pay for the prophylaxis. You say that the treating provider is in-network and this service
should be approved. The Plan denied your request. The Plan says your plan does not allow payment for
services that are billed by non-participating providers. The Plan also says that this treating provider does not
participate with your 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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the
prophylaxis provided on April 19, 2021 by an 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 this enrollee is stable and suitable for transfer to an LTAC. The Plan states the enrollee cannot be adequately care for in their current condition at a skilled nursing facility or any other lower level 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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided on October 5, 2020.
You asked the Plan to pay for the moderate sedation services (99152). You say that the services were necessary because the procedure requires the enrollee to remain motionless for a prolonged period of time or in a painful position. The Plan denied your request. The Plan says there is no record of severe anxiety, psychiatric comorbidities or other circumstances that might have warranted intravenous sedation.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no record of a medical condition requiring MAC. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services (99152) have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided on October 5, 2020.