Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement of the copayment for the urgent care office visit (99213, S9088) provided on April 30, 2021.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 urgently needed services provided at an urgent care center. You have been asked to pay a $35 copayment for the office visit provided at an urgent care center. 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 issue reimbursement of the copayment for the urgent care office visit (99213, S9088) provided on April 30, 2021.
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 you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoperative neurophysiology monitoring and electromyography provided on May 4, 2020.

You asked the Plan to pay for the intraoperative neurophysiology monitoring and electromyography (95938, 95940, 95861). You say that the services are not bundled or inclusive to the facility charges. The Plan denied your request. The Plan says this provider is not a recognized facility or legally qualified physician therefore services are not payable.

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 intraoperative neurophysiology monitoring and electromyography provided on May 4, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the oncology visit. We decided that the Plan does not have to waive the copayment for the outpatient hospital clinic visit.
You asked the Plan to waive the copayments for the outpatient hospital clinic visit and oncology visit. You say that you feel as though you are being double-charged for the same services. The Plan says that you were charged these copayments correctly. The Plan says that for the outpatient hospital clinic visit, since the allowed amount for this service ($131.32) is less than your copayment obligation, you are responsible for the full allowed amount. The Plan also claims that you also have a separate copayment for specialist visits.
We decided that the Plan has to waive the copayment for the oncology visit.
According to your Evidence of Coverage (EOC), when you receive services at an outpatient hospital, you have a $435 copayment. However, the EOC also states that this copayment includes hospital or other facility charges and physician or surgical charges. The wording of the EOC indicates that if you receive physician services while in an outpatient hospital facility, the cost sharing for those physician services is included in the cost sharing for the outpatient hospital facility. It would be unreasonable for the Plan to expect an enrollee to think that a separate copayment could possibly apply for physician services that occur during an outpatient hospital visit. Therefore, we decided that the Plan has to waive the copayment for the oncology visit.
We also decided that the Plan does not have to waive the copayment for the outpatient hospital clinic visit.
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 $435 copayment for the outpatient hospital clinic visit. Since the allowed amount for this outpatient hospital clinic visit is less than your copayment obligation, you can only be held responsible for the allowed amount ($131.32) Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital clinic visit.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that it would be unsafe for the enrollee to return home at this point. The Plan denied your request. The Plan says the enrollee exceeds mobility and activities of daily living criteria for a continued SNF stay.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee no longer qualifies for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingival irrigation (D4921) provided on April 28, 2021.

You asked the Plan to pay for gingival irrigation. You say that you want the Plan to pay. The Plan denied your request. The Plan says the service at issue is not a covered 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 gingival irrigation (D4921) provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3320) provided on January 12, 2021.

You asked the Plan to pay for the endodontic therapy. You say that during your call with the Plan you were advised that the root canal would be covered or partially covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

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. The record shows that you contacted the Plan on December 30, 2020, to ask what PPO (Preferred Provider Organization) stood for, and if you had to pay up front for services and could be reimbursed. You were advised that if you were having services over $300 you should get a predetermination to see if the services were covered. The record also shows that you did not call to verify these services you were receiving on January 12, 2021. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (D3320) provided on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 4, 2021.

You asked the Plan to pay for these services. You say that you did not know this doctor did not participate in Medicare. The Plan denied your request. The Plan says the Plan contract is clear that enrollees must use Medicare providers.

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 Medicare program. Enrollees are expected to confirm the providers they are using are eligible providers. Therefore, we decided that the Plan does not have to pay for physician services provided by Gerard A. Malanga, MD on March 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on February 2,
2021.
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says code 99601 is assigned a status code of "I" and is excluded from payment
for Medicare claims. Medicare uses a different code to report these services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due
to an issue with the status code indicator for the billed code. A corrected claim is required with the appropriate
code. Therefore, we decided that the Plan does not have to pay for home health services provided to the
enrollee on February 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81286, 81404, 81407, 81408 and 81479) provided December 29, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is non-covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented cardiovascular disease. We looked at the file and Medicare rules. The service at issue is cardiovascular risk assessment testing, which is not covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81286, 81404, 81407, 81408 and 81479) provided December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee out of network on August 18, 2020.

You asked the Plan to pay for out-of-network services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 service 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 services provided to the enrollee out of network on August 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (88305) rendered by the out-of-network (OON) provider on February 4, 2021.
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 laboratory service (88305) rendered by the out-of-network (OON) provider on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care provided on March 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the wound care. You say that the service was medically necessary The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 wound care provided on March 11, 2021 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 first 15 minutes of deep sedation/general anesthesia (D9222) and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223) provided on April 7, 2021.

You asked the Plan to pay for the deep sedation/general anesthesia. You say that you believe the anesthesia should be covered. The Plan denied your request. The Plan says the anesthesia is not covered because the surgical extraction the anesthesia was provided with is 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, deep sedation/general anesthesia is not among those covered under this benefit when provided with a non-covered service. Therefore, we decided that the Plan does not have to pay for the first 15 minutes of deep sedation/general anesthesia (D9222) and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223) provided on April 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hospital observation care (G0378, 99285) provided from April 16, 2021, through April 17, 2021.

You asked the Plan to waive the copayment for hospital observation care. You say that you should not be responsible for these charges. 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 $225 copayment for outpatient hospital observation.

You have been asked to pay a $225 copayment for hospital observation care. The services at issue fall within the outpatient hospital observation 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 hospital observation care (G0378, 99285) provided from April 16, 2021, through April 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998-RR) provided on May 5, 2021.

You asked the Plan to pay for the ambulance service. You say that you saw no reason to be transported to the hospital. You say that you feel that the services should be covered as urgently needed care, per page 50, section 2 of the Medicare and You booklet. You also say that you will pay the copayment. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. The Plan says that when transportation is not provided, the service is not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on May 5, 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 the ambulance response and treatment, no transport (A0998-RR) provided on May 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance services (A0426HH, A0425HH) provided on March 21, 2021.

You asked the Plan to waive the copayment for non-emergency ambulance services. You say that the claim should be covered in full. 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 $300 copayment for ambulance services. 

You have been asked to pay a $300 copayment for non-emergency ambulance services. The service at issue 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 non-emergency ambulance services (A0426HH, A0425HH) provided on March 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two stage lumbar fusion.
You asked the Plan to pre-approve lumbar arthrodesis; arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar (22558). You say that the enrollee has done more than 6 weeks of conservative treatment and displays segmental decrease in sensory and motor. The Plan denied your request. The Plan says fusions are not appropriate when more than one level is needed and there does not appear to be spine instability.
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 lumbar arthrodesis; arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar (22558). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for fusion not met. There is no documented spinal instability fracture or tumor. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar arthrodesis; arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar (22558) have not been met. Therefore, we decided that the Plan does not have to pre-approve two stage lumbar fusion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incomplete root canal (D3332) for tooth # 2 provided on
December 23, 2020.
You asked the Plan to pay for the dental service. You say that you received a bill for $400 for this service. You
also say that this should be covered. The Plan denied your request. The Plan says incomplete root canal is not
listed as 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 incomplete root canal is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the incomplete
root canal (D3332) for tooth # 2 provided on December 23, 2020.