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

We decided that the Plan does not have to waive the copayments for a debridement of subcutaneous tissue
procedure (11042) performed on January 7, January 14, and January 28, 2021.
You asked the Plan to waive the copayments for a debridement of subcutaneous tissue. You say that these bills
are in error due to the services you received. 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 $320
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.
You have been asked to pay a $960, or a $320 copayment for each performance of a debridement of
subcutaneous tissue. A debridement of subcutaneous tissue falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 a debridement of subcutaneous tissue procedure (11042) performed on January 7, January 14, and January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Volara system (E1399), by a non-participating plan provider.
You asked the Plan to pre-approve a Volara system. You say that the item is medically necessary. The Plan denied your request. The Plan says items must be purchased by participating plan providers.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a Volara system (E1399), by a non-participating plan provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care
after June 27, 2021.
You asked the Plan to pre-approve the continuation of SNF care. You say that the enrollee continues to require
SNF care. The Plan denied your request. The Plan says SNF care is no longer medically reasonable and
necessary.
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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found while there continue to be identifiable skilled nursing service needs, there are no longer identifiable skilled therapy service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary does not meet severity of illness or intensity of service criteria for 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 the continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after June 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided
on January 5, 2021.
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you were billed
for individual tests and not a preventive appointment. You say that your previous visits were fully covered, and
this should be considered a zero-cost preventive visit. The Plan denied your request. The Plan says the claim
reprocessed to only apply a $40 copayment.
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 diagnostic procedures and tests.
You have been asked to pay a $40 copayment for the myocardial perfusion imaging. The myocardial perfusion imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The myocardial perfusion imaging is considered a diagnostic service. 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 myocardial perfusion imaging provided on January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355).
You asked the Plan to pre-approve the dental service. You say that this procedure will improve your overall health. You also say that your dental issues cause you additional anxiety. The Plan denied your request. The Plan says full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit is not covered when performed less than 1 year after an evaluation. The Plan also says that the frequency limit has been exceeded.
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 dental service when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Specifically, the record shows that you received an evaluation within 1 year of this request. Therefore, we decided that the Plan does not have to pre-approve full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injections and contrast material provided by an out-of-network provider on April 19, 2018.

You asked the Plan to pay for the injections and contrast material. You say that you didn't receive a response for insurance so you resubmitted the denial. You say that the medical records support the necessity of the service performed and the claim should be reimbursed. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and in-network providers were available.

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 injections and contrast material provided by an out-of-network provider on April 19, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) care provided to the enrollee from June 26, 2021, forward.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 continuation of skilled nursing facility (SNF) care provided to the enrollee from June 26, 2021, forward.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on
January 5, 2021.
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you paid your
copayment for the MRI and you had to go back because they did not get a good result. You say that you should
not be charged an extra $50. 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 $50
copayment for x-rays at an in-network provider.
You have been asked to pay a $50 copayment for the diagnostic mammogram. The diagnostic mammogram
falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for the diagnostic mammogram provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for telehealth services provided on January 5, 2021.
You asked the Plan to waive the copayment for telehealth services. You say that this was a phone call for a prescription refill and you feel that you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $45 copayment for telehealth services provided by a specialist. You have been asked to pay a $45 copayment for telehealth services. Telehealth services fall within the physician/practitioner services, including doctor's office 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 copayment for telehealth services provided on January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an autogenous connective tissue graft procedure (D4273
x2).
You asked the Plan to pre-approve an autogenous connective tissue graft procedure. You say that the service at
issue is medically necessary. 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 pre-approve an
autogenous connective tissue graft procedure (D4273 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on January 20, 2021 by an out of network (OON) provider.
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and paid. You say that the member's primary care physician referred these services. The Plan denied your request. The Plan says prior authorization was not obtained 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 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 outpatient services provided on January 20, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care discharge management provided by an out of-network provider on January 1, 2021.

You asked the Plan to pay for the observation care discharge management. You say that the provider was the on-call physician during the observation stay and the claim should be reconsidered for payment. The Plan denied your request. The Plan says this provider is not in-network and there is no authorization on file.

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 observation care discharge management provided by an out of-network provider on January 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on December 21, 2020.
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you would like this service to be covered. The Plan denied your request. The Plan says your benefits for this service had been satisfied and the frequency limitation had been exceeded.
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, intraoral x-rays are limited to one procedure per calendar year. The record shows that you received two intraoral periapical x-rays on December 21, 2020, one of which was covered by the Plan, and your intraoral x-rays benefit had been exhausted.
Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on December 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for tumor removal (27045) and a muscle graft (15734) provided
on December 16, 2020.
You asked the Plan to pay for tumor removal and a muscle graft. You say that this should be covered. The Plan
denied your request. The Plan says this was not billed with a required modifier.
The Plan must follow Medicare rules. Medicare rules say that while Medicare does not include payment for
treatment for postoperative complications which requires a return trip to the operating room in the Global
Surgical Package for a procedure, these return trips should be reported with modifier "-78."
We looked at the file and Medicare rules. The services at issue were performed during the global period of an
abscess drainage (26990) that was performed on November 30, 2020. While the record shows that the services
at issue were treatment for postoperative complications that required a return trip to the operating room, these
services were not reported with modifier "-78" as required. Based on this information, we decided that
Medicare rules for coverage of tumor removal and a muscle graft have not been met. Therefore, we decided
that the Plan does not have to pay for tumor removal (27045) and a muscle graft (15734) provided on
December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided by an out-of-network
provider on January 6, 2021.

You asked the Plan to pay for the nursing facility visit. You say that the physician provided medically
necessary services and is seeking reimbursement. You say that the services rendered are consistent with the
principles of medical practice and the claim should be processed for payment. The Plan denied your request.
The Plan says prior authorization was required but not 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 nursing facility visit provided by an out-ofnetwork
provider on January 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 31, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
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 August 31, 2020. 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 services provided on August 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the HHA or CNA, providing care in the home provided on
January 1, 2021, and January 2, 2021.
You asked the Plan to pay for the HHA or CNA. You say that you believed you would be reimbursed for these
services. The Plan denied your request. The Plan says you received services from a provider who is not under
contract with the health plan and is not certified for Medicare.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items
or services, a provider or supplier must be enrolled in the Medicare program.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the HHA or CNA have not been met. Therefore, we decided that the Plan does not have to pay for
the HHA or CNA, providing care in the home provided on January 1, 2021, and January 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on November 12, 2020.

You asked the Plan to pay for the office visit. You say that you are receiving prior authorization denials due to a provider ID issue and the claim should be reprocessed. The Plan denied your request. The Plan says prior authorization was required but not 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 office visit provided by an out-of-network provider on November 12, 2020.
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
February 25, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that the exam should be
covered at the out-of-network rate because it was medically necessary. The Plan denied your request. The Plan
says this service 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, 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
problem focused limited oral evaluation provided on February 25, 2021.