Persius/hicric huggingface dataset:
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 January 2, 2020 to January 30, 2020.You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says payment is not allowed for this service because it was billed with an incorrect type of bill code for claim reconsideration.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, this claim has been submitted with an invalid type of bill code for home health services..Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 2, 2020 to January 30, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ER visits provided from March 13, 2020 to March 15, 2020.You asked the Plan to waive the copayment for ER visits. You say that you request that one of the ER copayments be waived because they were both related to the same condition.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 $120 copayment for emergency care.You had an ER visit on March 13, 2020. Therefore, you are responsible to pay a $120 copayment. You had an ER visit from March 14, 2020 to March 15, 2020. This is considered a new ER visit. Therefore, you are responsible to pay the $120 copayment. Therefore, the total amount you owe is: $240. You have been asked to pay the total copayment amount of $240 for ER visits. ER visits fall within the emergency 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 copayment for ER visits provided from March 13, 2020 to March 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on December 19, 2019.You asked the Plan to pay forthe ambulance services. You say that you did not want transported to the hospital.The Plan denied your request. The Plan says that the co-payment in question is not a covered benefit under the member's contract under any normal circumstance.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 December 19, 2019. 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 forthe ambulance services provided on December 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for Computed Tomography (CT) scans
(70482, 70470) performed January 7, 2020.
You asked the Plan to waive the copayments for the CT scans. You say that the copayments should be waived
because the service only lasted 10 minutes. The Plan denied your request. The Plan says two CT scans were
performed, so 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 $100
copayment for Diagnostic Radiology.
You have been asked to pay a $200 copayment for two CT scans. The CT scans fall within the Diagnostic
Radiology 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 Computed Tomography
(CT) scans (70482, 70470) performed January 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran eye exam (92014) and cataract surgery (66821) provided from December 9, 2019 to December 11, 2019.You asked the Plan to waive the copayment foran eye exam and cataract surgery. You say that these services should be fully covered.The Plan denied your request. The Plan says these services 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). Your contract with the Plan clearly says that you must pay pay a $40 copayment for each specialist office visitand a $175 copayment for Medicare-covered surgery services at an ambulatory surgical center.You have been asked to pay $40for an eye exam, which is considered a specialist office visit,and $175 for cataract surgery. This means that you have been askedto 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 foran eye exam (92014) and cataract surgery (66821) provided from December 9, 2019 to December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient
(D0150) provided on February 10, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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.
You exhausted your benefit frequency limit, because you had this same service done on August 28, 2019. Your
EOC states, comprehensive oral evaluation - new or established patient (D0150) - one (1) procedure every
three (3) plan years. Therefore, we decided that the Plan does not have to pay for comprehensive oral
evaluation - new or established patient (D0150) provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveanesthesia services (01992) provided on December 2, 2019.You asked the Plan to pre-approvethe anesthesia service. You say that you would like reconsideration because this service was medically necessary.The Plan denied your request. The Plan says the medical record does not show a rare and unique circumstance to support this service.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 andapply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the anesthesia service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was nothing in the enrollee's record indicating that it was medically necessary to have an anesthesiologist present during the transforaminal ESI.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 anesthesia service have not been met.Therefore, we decided that the Plan does not have to pre-approveanesthesia services (01992) provided on December 2, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSNF care from November 8, 2019 through November 15, 2019 provided by an out-of-network provider.You asked the Plan to waive the copayment forSNF care. You say that you were told by the hospital that it would be covered in full.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received SNF care from November 8, 2019 through November 15, 2019 provided by an out-of-network provider. You are asked to pay 30% coinsurance for the SNF care you received. Your EOC states, enrollees must pay 30% coinsurance per day for days 1-100 for out-of-network SNF care. 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 forSNF care from November 8, 2019 through November 15, 2019 provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 25, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 February 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on August 6, 2019.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the record. Specifically, the record does not indicate that 30-74 minutes of critical care services were rendered. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on August 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown and restorative procedure provided on January 28, 2020.
You asked the Plan to pay for the crown and restorative procedure. You say that you had these services provided on this date because the letter said they were approved. You also say that the dental office was not aware that your benefits had changed. The Plan denied your request. The Plan says your dental plan for 2020 does not show that you have the optional benefit that covers comprehensive dental services.
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 crown and restorative procedure provided on January 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the inpatient hospital care provided October 14, 2019 to October 20, 2019.You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the copayment has been applied correctly to the inpatient hospital careprovided.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 paya $370 copayment per day for days 1-5, for inpatient hospital care. You have been asked to pay a $1,850 copayment ($370 x 5 days) fortheinpatient hospital care provided. 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 copaymentfor the inpatient hospital care provided October 14, 2019 to October 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Skilled Nursing Facility services provided on December 1, 2019 through December 6, 2019.
You asked the Plan to pay for the Skilled Nursing Facility services. You say that you would like reconsideration based on the record submitted. The Plan denied your request. The Plan says the claim submitted includes invalid data for processing.
The Plan must follow Medicare rules. Medicare rules say that bills that are missing required rehabilitation therapy ancillary revenue codes are to be returned to the Skilled Nursing Facility for resubmission. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Skilled Nursing Facility services have not been met. Specifically, the claim at issue does not include valid revenue codes for the HIPPS rate codes submitted. Therefore, we decided that the Plan does not have to pay for Skilled Nursing Facility services provided on December 1, 2019 through December 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant, cone beam CT capture and interpretation with field of view of both jaws, and adjunctive procedure provided on November 18, 2019.
You asked the Plan to pay for the endosteal implant, cone beam CT capture and interpretation, and adjunctive procedure. You say that the Plan representative you spoke with told you that these procedures were covered by your existing contract. The Plan denied your request. The Plan says these services are not covered benefits.
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 surgical placement of implant body: endosteal implant, cone beam CT capture and interpretation with field of view of both jaws, and adjunctive procedure provided on November 18, 2019.
Your complaint about being disappointed in the Plan's quality of service is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on October 9, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says out-of-network services are not covered.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says thatthe 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 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 forthe medical services provided to you by an out-of-network provider on October 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the knee surgery rendered on October 3, 2019.
You asked the Plan to waive the deductible for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the deductible was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $500 yearly deductible for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on October 3, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the knee surgery rendered on October 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewerfound the enrollee is currently undergoing treatment at an acute care hospital (ACH) for ongoing complications following a gunshot wound (GSW) to the abdomen in May 2019. The enrollee is receiving wound care, supplemental nutrition and antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on October 26, 2019 through October 29, 2019.You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the services billed.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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.We find that CPT code 99291 is not supported in the record. Specifically, the record does not indicate that 30-74 minutes of critical care services were rendered. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met.Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on October 26, 2019 through October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (99202, 97112, 97530, 98941) provided on December 21, 2019 to January 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON chiropractic services. You say that these services helped you heal from bicycle accidents. The Plan denied your request. The Plan says these services were not authorized.
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 chiropractic services (99202, 97112, 97530, 98941) provided on December 21, 2019 to January 30, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency care you received from August 20, 2019, to August 23, 2019.You asked the Plan to pay forthe emergency care. The Plan denied your request. The Plan says you did not submit proof of payment.The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, much furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The documentation provided does not contain a proof of payment for the services in question. Without a proof of payment, it cannot be determined whether payment is due, and the amount of payment. Based on this information, we decided that Medicare rules for coverage of the emergency care have not been met.Therefore, we decided that the Plandoes not have to pay forthe emergency care you received from August 20, 2019, to August 23, 2019.