Persius/hicric huggingface dataset:
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 February 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON provider.
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 has network providers available who can provide 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 February 18, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 01230 provided on November
23, 2019.
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 01230 is anesthesia for open procedures involving upper
two-thirds of femur; not otherwise specified.
We find that CPT code 01230 is not supported in the medical record. Specifically, the documentation indicates
that anesthesia for humerus was performed. There is a more appropriate CPT for the services provided. Based
on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met.
Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 01230 provided on
November 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopedic referral to an out of area (OOA), out of
network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network
provider.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.
We looked at the file and Medicare rules. No documentation was submitted that would prove that the requested
out of area, out of network services would be medically necessary. Based on this information, we decided that
Medicare rules for coverage of these OON services have not been met. Therefore, we decided that the Plan
does not have to pre-approve an orthopedic referral to an out of area (OOA), out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit you had on November 7, 2019.
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this service exceeds the
benefit limit.
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 $0
copayment for an annual wellness visit once every 12 months.
The records show that you had an annual wellness visit on November 7, 2019. The records also show that you
had a covered wellness visit on May 14, 2019. This means that the requested visit exceeds the benefit limit.
This means that you have been asked to pay the correct amount based on your contract with the Plan.
Therefore, we decided that the Plan does not have to pay for the annual wellness visit you had on November 7,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on January 7, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that this was a follow-up visit to a laser procedure and you do not believe you should be liable for the copayment. The Plan denied your request. The Plan says you have been charged 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 $50 copayment for a specialty physician. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a 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 specialist office visit provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 17, 2019 to
December 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you were told that this provider was in-network.
The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are
in-network providers available for these services.
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 has network providers
available who can provide 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 physician services provided on December 17,
2019 to December 30, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on
November 18, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this exam
was billed incorrectly. The Plan denied your request. The Plan says you had exhausted your exams benefit. The
Plan also says that you were not eligible for an additional exam.
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, oral examinations are limited to two
per calendar year. The record shows that you received periodic oral evaluations on March 28, 2019 and
October 14, 2019 and your oral examinations benefit had been exhausted. Therefore, we decided that the Plan
does not have to pay for the problem focused limited oral evaluation provided on November 18, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the psychotherapy visits provided from
October 31, 2016 to October 14, 2019.
You asked the Plan to waive the copayments for the psychotherapy visits. You say that you are appealing these
claims. The Plan denied your request. The Plan says you have been charged 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 $40
copayment for an in-network specialist's office.
You have been asked to pay a $40 copayment for each of the psychotherapy visits. ($40 x 20 visits = $800).
You have been asked to pay a $33.87 copayment for the visit on August 8, 2017, which is less than the
standard copayment. ($800 + $33.87 = $837.87). The psychotherapy visits fall within the "Outpatient mental
health care" 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 the psychotherapy visits provided from October 31, 2016 to
October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 11, 2019.
You asked the Plan to pay for the physician's services. 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 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 physician's services provided on December 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that bisphosphonate injections (administered intravenously [IV]) will be covered when specific criteria is met. 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 Prolia. Our reviewer says that the medication is not medically necessary. Our physician reviewer found there has not been a trial and failure of oral or intravenous bisphosphonate therapy. There is no documentation that the enrollee is supplementing with 1,000 mg of calcium per day. Therefore, the enrollee does not meet the coverage criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the Botox injection provided on February
5, 2020.
You asked the Plan to reduce the coinsurance for the Botox injection. You say that you were told you would
only have a $10 copayment. You say you cannot afford this bill. The Plan denied your request. The Plan says
you have been charged 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 each in-network Medicare-covered Part B drug.
You have been asked to pay $264.51 which is 20% of the allowed amount for the Botox injection. The allowed
amount is $1,322.57. ($1,322.57 x 20% = $264.51). The Botox injection falls within the "Medicare Part B
prescription drugs" 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 reduce the coinsurance for the Botox injection
provided on February 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 require skilled nursing
services to safely and effectively provide medically necessary and reasonable treatment beyond the last covered
day. The enrollee's functional level does not require skilled therapy services to safely and effectively provide
medically necessary and reasonable treatment only in a SNF. It is not medically reasonable and necessary to
provide skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis." As a
practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing
facility 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 skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 5, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay
for the laboratory services provided on August 5, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit and endoscopy provided from
November 17, 2019 through November 20, 2019
You asked the Plan to waive the copayment for the ER visit and endoscopy. You say that anything done in the
ER is covered under the ER copayment. 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 $90
copayment per emergency department visit and a $325 copayment for outpatient surgery.
You have been asked to pay a $90 copayment for the ER visit and a $325 copayment for the endoscopy. The
ER visit falls within the "Emergency care" benefit category. The endoscopy falls within the "Outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit
category. The records show that you were admitted to outpatient observation prior to the endoscopy, therefore a
separate copayment applies.
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 ER visit and endoscopy provided from November 17,
2019 through November 20, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 7, 2020 by an out
of network provider.
You asked the Plan to pay for the medical services. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says you did not request 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 has network providers
available who can provide 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 medical services provided on January 7, 2020
by an out of network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from August 4, 2019 to October 2, 2019.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, a required Q code to indicate where home health services were provided was not reported along with the first billed home health service. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from August 4, 2019 to October 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other
medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly
minimal/standby assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer
duration of therapy will allow for measurable gains to be achieved within a reasonable and predicted time
frame.
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 28,
2020 to January 29, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that services rendered met criteria for
inpatient. The Plan denied your request. The Plan says that inpatient care was not medically necessary.
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 pay for acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. The
record did not show that at the time of inpatient admission the admitting physician reasonably expected that the
patient's necessary hospital care (including earlier emergency department and/or observation care) would span
two midnights. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for
inpatient care.
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 pay for the acute inpatient hospital care provided from January 28, 2020 to January 29,
2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on August 1,
2019.
You asked the Plan to pay for the hospital outpatient clinic visit. You say that this claim has not been paid in
full or under the terms of the contract for the services provided to this enrollee. The Plan denied your request.
The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or
unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on August 1,
2019.