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

We decided that the Plan does not have to pay for x-ray transportation services (R0070) provided on November 20, 2020.
You asked the Plan to pay for x-ray transportation services. You say that this should be covered. The Plan denied your request. The Plan says this cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that when a skilled nursing facility (SNF) resident receives a portable x-ray service during the course of a Medicare-covered stay in the SNF, the technical component representing the procedure itself, including any associated transportation and setup costs, would be subject to consolidated billing and must be included on the SNF's Part A bill for the resident's covered stay. We looked at the file and Medicare rules. The record shows that the x-ray transportation services at issue were provided to an enrollee in a covered SNF stay. These services are subject to consolidated billing and are not separately payable from the SNF stay. Based on this information, we decided that Medicare rules for coverage of x-ray transportation services have not been met. Therefore, we decided that the Plan does not have to pay for x-ray transportation services (R0070) provided on November 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from November 19, 2020, through November 24, 2020.

You asked the Plan to waive the copayment for the inpatient stay. You say that you were charged for days when you were ready to be discharged. You say that you should only be responsible for two days. 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 $185 copayment per day for days 1-7 for each Medicare-covered hospital stay. 

You have been asked to pay a $925 copayment for the inpatient stay. ($185/day x 5 days = $925). The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show you were an inpatient for 5 days. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from November 19, 2020, through November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a spectacle fitting (92341) provided on November 9, 2020.
You asked the Plan to pay for the spectacle fitting. You say that this enrollee resides in a nursing home and had no choice in who provided the care. This provider was referred by the facility. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental vision benefit, nor was it provided in-network. The referring facility is not contracted with the Plan. Payment cannot be made.
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 contract with the Plan also 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. We looked at the file and the Plan's rules. A spectacle fitting is not covered by Medicare or by the Plan's supplemental benefit. These services were also provided out-of-network. 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 spectacle fitting have not been met. Therefore, we decided that the Plan does not have to pay for a spectacle fitting (92341) provided on November 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aquatic/Water therapy.
You asked the Plan to pre-approve the Aquatic/Water therapy. You say that you would like aquatic therapy for your recent hip fracture. You say that your physical therapist has recommended this therapy. The Plan denied your request. The Plan says you are weight bearing and you have participated in and tolerated land based physical therapy.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Aquatic/Water therapy. Our reviewer says that the requested Aquatic/Water therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested Aquatic/Water therapy exceeds your functional needs and is not medically necessary per the Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k). The requested therapy is not generally accepted as specific and effective therapy for your condition. You have had prior land-based therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. You have been instructed in and you are compliant in a home exercise program. The medical documentation does not support the need for supervised therapy or inability to tolerate land-based therapy. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 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 Aquatic/Water therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Aquatic/Water therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for 2 office visits (99214) provided on
December 11, 2020, & December 30, 2020.
You asked the Plan to waive the copayments for the office visits. You say that the copayments should be
waived. The Plan denied your request. The Plan says the correct copayments were 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 specialist visits.
You have been asked to pay a $45 copayment for each office visit for a total of $90. The office visits fall within
the specialist visits 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 copayments for 2 office visits
(99214) provided on December 11, 2020, & December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related services provided on October 15,
2020, by an OON provider.
You asked the Plan to pay for the office visit and related services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered
benefit.
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 the office visit and related services provided on
October 15, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine eye examination (refraction) provided on October 20, 2020.

You asked the Plan to pay for routine eye exam. You say that you have been enrolled in this Plan with no lapse in coverage. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the Plan only covers one routine eye exam per calendar year and you previously received one on June 8, 2020.

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 one routine eye exam every calendar year. 

We looked at the file and the Plan's rules. You received a refraction on June 8, 2020; therefore, your routine eye exam benefit was exhausted for 2020. Based on this information, we decided that the Plan's rules for coverage of routine eye exam have not been met. Therefore, we decided that the Plan does not have to pay for a routine eye examination (refraction) provided on October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fitness equipment (A9300) purchased on February 9, 2021.
You asked the Plan to pay for fitness equipment. You say that this equipment and exercise was recommended to you by your physician, and with the pandemic making gym membership usage risky, you hope that the Plan will honor a purchase of equipment rather than a membership. The Plan denied your request. The Plan says fitness equipment is not listed as a covered benefit under your supplemental health and wellness benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan can pay for membership in a qualified health club or fitness facility, covered instructional fitness classes, participation in wellness programs, acupuncture and/or covered nutritional counseling sessions with a licensed nutritional counselor or registered dietitian. Fitness equipment is not listed as a covered benefit.
The Plan's rules for coverage of gym benefits have not been met because fitness equipment is not a covered item or service under the supplemental health and wellness benefit. Therefore, we decided that the Plan does not have to pay for fitness equipment (A9300) purchased on February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203), CT scan of the face (70486), oral device/appliance (E0486), and replacement of missing or broken teeth (D5520) provided from August 18, 2020, to October 1, 2020.

You asked the Plan to pay for the outpatient office visit, CT scan of the face, oral device/appliance, and replacement of missing or broken teeth. The Plan denied your request. The Plan says the treating provider has opted out of the Medicare program and cannot bill for non-emergent services. The Plan also says that D5520 is not covered.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203), CT scan of the face (70486), oral device/appliance (E0486), and replacement of missing or broken teeth (D5520) provided from August 18, 2020, to October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and bitewing x-rays provided on November 25, 2020.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and bitewing x-rays. You say that you believe these services should be covered. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective February 25, 2016, to February 25, 2022. The Plan also says that services performed by a privately contracted 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, the requested items or services are not covered when they are rendered by a provider who has opted out of Original Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and bitewing x-rays provided on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health services provided on May 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that you were never notified about new services or that you must be participating. The Plan denied your request. The Plan says prior authorization was not obtained as required.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the behavioral health services provided on May 11, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removable unilateral partial denture, two surgical placements of an implant body: endosteal implants, prefabricated abutment, provisional pontic, and bone replacement graft for ridge preservation provided on February 16, 2021.

You asked the Plan to pay for the removable unilateral partial denture, endosteal implants, prefabricated abutment, provisional pontic, and bone replacement graft. You say that the Plan must reimburse you 65% because these services are covered. 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 removable unilateral partial denture, two surgical placements of an implant body: endosteal implants, prefabricated abutment, provisional pontic, and bone replacement graft for ridge preservation provided on February 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0427) provided December 31, 2020.

You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for ambulance services. 

You have been asked to pay a $275 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 an ambulance transport (A0427) provided December 31, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound of heart with color-depicted blood flow, rate, direction and valve function provided on November 13, 2020.
You asked the Plan to pay for the ultrasound. You say that hospice was revoked and does not cover this date of service. 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on November 11, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the ultrasound of heart with color-depicted blood flow, rate, direction and valve function provided on November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the physician provided medically necessary services in good faith. The Plan denied your request. The Plan says prior authorization was not obtained as required.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit provided on December 6, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the medical services provided from January 6, 2020, to December 7, 2020.

You asked the Plan to waive the cost shares for the services provided. You say that you have spent more money out-of-pocket than the Plan claims. The Plan denied your request. The Plan says the claims processed 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).

The file shows that specialist office visits were provided on January 16, 2020, March 13, 2020, April 17, 2020, May 1 and 22, 20202, June 5, 2020, July 15, 2020, August 10, 2020, November 9, 2020, and December 7, 2020. A $20 copay was applied to each date of service. The services fall within the physician services benefit category.

The file shows that you received surgery services at an outpatient hospital on January 27, 2019. $789.38 was applied, which allowed you to reach your deductible amount. A $250 copay was then applied. You also received outpatient surgery services on May 15, 2020, June 8, 2020, July 2, 2020, October 19, 2020, and November 19, 2020. A $250 copay was applied to each date of service. These services were billed by the hospital facility. The services fall within the outpatient hospital services benefit category.

The file shows that outpatient surgery services were billed by your physician on January 27, 2020. You were charged $210.62 for the services. Because the amount is less than the $250 copay, you were charged the lesser amount. The services fall within the outpatient surgery benefit category.

The file shows that you received a walking boot on April 17, 2020. You were charged a 20% coinsurance for this item. The service falls within the durable medical equipment benefit category.

The file shows that you received physical therapy services on August 31, 2020, September 4, 9, and 28, 2020. A $40 copay was applied to each date of service. The physical therapy services provided on August 26, 2020, were reprocessed with a $20 copay. The services fall within the outpatient rehabilitation services benefit category.

The file shows that you received magnetic resonance imaging (MRI) services on October 28, 2020. A $75 copay was applied. The services fall within the outpatient diagnostic tests benefit category.

The file shows that you have been asked to pay the correct amounts 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 cost shares for the medical services provided from January 6, 2020, to December 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the member is not stable
enough for discharge and might be a danger to herself. The Plan denied your request. The Plan says that the
records received show that the enrollee's condition has improved, and she is no longer a threat to herself or
others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the
enrollee. The enrollee does not appear to require inpatient mental health treatment as she is not a danger to
herself or others and does not have any auditory or visual hallucinations while being cooperative with
treatment. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for
inpatient psychiatric 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 psychiatric hospital services have not been met. Therefore, we decided
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.