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

We decided that the Plan does not have to waive the copayments for the laboratory work provided on January
3, 2019 and January 31, 2019.
You asked the Plan to waive the copayments for the laboratory work. You say that you have never had to pay a
copayment for blood work for warfarin and you say you should not have to pay. 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 $15
copayment per visit for laboratory tests, non-radiological tests, diagnostic tests, flat film x-rays, and
ultrasounds. For each date of service, you have been asked to pay the allowed amount of the claim because
these amounts are less than the $15 copayment for the laboratory work.
You have been asked to pay a $4.37 copayment for the laboratory work on January 3, 2020 and a $4.29
copayment for the laboratory work on January 31, 2020. The laboratory work 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 copayments for the laboratory work provided on January 3, 2019 and
January 31, 2019.
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact
the plan directly.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames and lenses purchased July 8, 2019.
You asked the Plan to pay for the vision services. You say that you had to pay for your eyeglasses out of pocket and you would like your money back. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when the services are received from a participating provider. We looked at the file and the Plan's rules. supplemental vision services must be received from a participating provider in order to be covered by the plan. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for frames and lenses purchased July 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on February 20, 2020.You asked the Plan to pay for the pathology 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 pathology services provided on February 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically necessary. The Plan denied your request. The Plan says rules for coverage are not met.
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 reviewer found the enrollee's needs are met in the current acute care hospital setting. The records do not show that the enrollee would be need to participate in an intensive inpatient rehabilitation program. Rehabilitation needs can be met 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on October 22, 2019.You asked the Plan to waive the copayment for an office visit. You say that you feel that you are being overcharged for the copayment.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 $5 copayment for each primary care provider visit. You have been asked to pay a $5 copayment for an office visit. An office visit falls 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 an office visit provided on October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four 2D oral/facial photographic images (D0350 x4) and
resin-based composite (D2391) provided on January 17, 2020.
You asked the Plan to pay for the 2D oral/facial photographic images and resin-based composite. You say that
you were told these charges were covered before the work was done. You also say that you only went to get a
filling, and this provider rendered all kinds of work that you did not need. The Plan denied your request. The
Plan says these services are not covered under your contract under any normal circumstances.
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 four
2D oral/facial photographic images (D0350 x4) and resin-based composite (D2391) provided on January 17,
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health services provided October 2 to October 18, 2019.You asked the Plan to pay for the inpatient mental health services. You say that the inpatient care was medically necessary.The Plan denied your request. The Plan says the enrollees needs could have been met at a lower level of care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient mental health services. Our reviewer says that the inpatient level care on the dates of service at issue was not medically necessary. Our physician reviewer found based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was not showing any acute threats to safety. 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 inpatient mental health services have not been met.Therefore, we decided that the Plan does not have to pay for inpatient mental health services provided October 2 to October 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the seat lift mechanism of the recliner provided on October 20, 2019 by an out of network provider.You asked the Plan to reimburse you for the seat lift mechanism. You say that you purchased from the out of network provider for the longer warranty The Plan denied your request. The Plan says you were approved for a seat lift mechanism from an in network provider only.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 reimburse you 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 item at issue in this appeal. The Plan did not pre-approve the item at issue from this provider.We found no exception that would require the Plan to reimburse you for this item.Therefore, we decided that the Plan does not have to reimburse you for the seat lift mechanism of the reclincer provided on October 20, 2019 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the 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 reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH)
following gallbladder surgery. 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-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on February 16, 2020.
You asked the Plan to waive the copayment for an ER visit. You say that you were misdiagnosed during a
previous ER visit and had to return and feel that you should not owe a second copayment. 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 $90
copayment for emergency care.
You have been asked to pay a $90 copayment for an ER visit. An ER visit falls 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 an ER visit provided on
February 16, 2020.
We note your complaint that you were misdiagnosed during a previous ER visit. Your complaint is a grievance
that must be answered by the health plan. Medicare does not permit us to make a decision about these types of
complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron Tab 8mg (J8597).
You asked the Plan to pre-approve Ondansetron Tab 8mg. You say that the requested medication is not
medically necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare
Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not
meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron Tab 8mg
(J8597).
Benefits for Ondansetron Tab 8mg may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99221, 1123F, 99232) provided on July 9,
2018 to July 10, 2018.
You asked the Plan to pay for hospital care. You say that this was filed timely. The Plan denied your request.
The Plan says this claim was filed more than a year after the services were rendered.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010
must be filed no later than one calendar year after the date of service.
The record shows that a claim for hospital care was not filed until August 22, 2019. This means that more than
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the
Plan does not have to pay for hospital care (99221, 1123F, 99232) provided on July 9, 2018 to July 10, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) for all 4 quadrants provided on November 15, 2019.

You asked the Plan to pay for the dental services. You say that you have gum disease. You say that you had to have laser surgery. You also say that a plan representative advised that the services should be covered. The Plan denied your request. The Plan says the services that you received are dental in nature. The Plan says the periodontal scaling and root planning is not covered.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) for all 4 quadrants provided on November 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Elenker Lighweight Rollator Walker
purchased on January 21, 2020.
You asked the Plan to reimburse you for the walker. You say that the Plan should reimburse you. The Plan
denied your request. The Plan says you obtained durable medical equipment from a provider who does not
participate with Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items provided directly by a provider who is not eligible to take Medicare payment.
Payment cannot be made for items purchased from this provider because this provider is not a medical provider
and is not enrolled in Medicare. Therefore, we decided that the Plan does not have to reimburse you for the
Elenker Lighweight Rollator Walker purchased on January 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 76770 provided on November 23, 2019.
You asked the Plan to pay for CPT code 76770. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must confirm that Medicare
coverage criteria have been met.
We looked at the file and Medicare rules. In this case, there was not sufficient medical records provided
confirming that Medicare criteria have been met. Therefore, we decided that the Plan does not have to pay for
CPT code 76770 provided on November 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient mental health care provided from July 20, 2019
to August 20, 2019.
You asked the Plan to pay for the inpatient mental health care. You say that the inpatient mental health care
provided from July 20, 2019 to August 20, 2019 was medically necessary. The Plan denied your request. The
Plan says the inpatient mental health care provided from July 20, 2019 to August 20, 2019 was not medically
necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the inpatient mental health care. Our
reviewer says that the inpatient mental health care provided from July 20, 2019 to August 20, 2019 was not
medically necessary. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric
hospital on July 20, 2019 with Major Depressive Disorder, Recurrent, Severe without Psychotic Features,
Sedative/Hypnotic/Anxiolytic Dependence with Withdrawal Unspecified, Posttraumatic Stress Disorder,
Alcohol Dependence Uncomplicated and Animus Dependence, Uncomplicated. Based upon review of the
records provided it was not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others (as noted on the suicide assessment form), auditory or visual
hallucinations, delusions and was not showing any behavioral issues or withdrawal symptoms. It did not appear
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather
than a lower level of care as he did not have dangerousness to self or others, perceptual disturbance including
auditory or visual hallucinations. This enrollee did not appear to require inpatient mental health treatment as he
was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment
was taking place. It did not appear that the services were reasonably expected to improve the enrollee's
condition or for the purpose of diagnosis. This enrollee was treated under an individualized treatment plan
found in the record. It did appear that the records were supervised and evaluated by a physician.
Based upon review of the records provided, the admission of this enrollee does not meet the criteria for acute
inpatient mental health treatment as this enrollee was not shown to be a danger to himself or others but was
without agitation or aggression without perceptual disturbance including auditory, visual hallucinations or
delusions.
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 inpatient mental health care have not been met. Therefore, we decided that
the Plan does not have to pay for the inpatient mental health care provided from July 20, 2019 to August 20,
2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the enrollee was over 362 miles from her
home when she began to feel ill. You say that she called 911 to seek medical guidance and decided to go to the
emergency room by personal vehicle rather than incur the ambulance transport expense. You stated that the
ambulance company provided the enrollee with medical care and should be compensated for the medical
response. 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 September 22, 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 for the ambulance services.