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

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 27, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 had network providers available who could have provided 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 for the services provided by an out-of-network provider on December 27, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on December
22, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you went for a COVID lab
test and did not request an assessment as part of the office visit. You say that neither you nor the Plan should
have been charged for this. 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 $35
copayment for urgently needed services at an in-network urgent care center.
You have been asked to pay a $35 copayment for the urgent care visit. The urgent care visit falls within the
"Urgently needed 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 the urgent
care visit provided on December 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says care could be received in another setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
acute respiratory failure, pneumonia and COPD and were discharged to a skilled nursing facility.

Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be
provided in a different level of care. There is not a reasonable expectation that you will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on July
29, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 had network providers
available who could have provided 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 for the services provided by an out-of-network provider on July 29,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia (D9222), radiological exam (X-ray) (D0330), and removal of 7 teeth (D7210), provided on February 10, 2021.
You asked the Plan to pay for the anesthesia, X-rays and tooth removal. You say that the services should be covered. The Plan denied your request. The Plan says you have exceeded your Plan's maximum benefit for the services provided.
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. Specifically, the services you received were above the Plan's maximum allowance. This means you are responsible for the difference.
Therefore, we decided that the Plan does not have to pay for anesthesia (D9222), radiological exam (X-ray) (D0330), and removal of 7 teeth (D7210), provided on February 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425, A0426) on August 9, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were told by the facility staff that you would not have a charge because the destination facility was part of the same hospital group. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $185 copayment for Ambulance Services. You have been asked to pay a $185 copayment for the ambulance transportation. The ambulance transportation 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 the ambulance transportation (A0425, A0426) on August 9, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan provided on December 21, 2020, by an OON
provider.

You asked the Plan to pay for duplex scan. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this service is correct, because this provider is
out-of-network with the Plan and authorization was 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 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 a duplex scan provided on December 21, 2020, by
an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 22, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 87150 and CPT 87491 remain not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 87150 and CPT 87491 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on October 28, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 15734 is not supported.
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 15734 is muscle, myocutaneous, or fasciocutaneous flap; trunk. We find that CPT code 15734 is not supported in the medical record. Specifically, there is no documentation of a muscle, myocutaneous, or fasciocutaneous flap from the trunk. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the tissue transfer provided on November 11, 2020 and the office visit provided on November 23, 2020.
You asked the Plan to waive the copayment for the tissue transfer and office visit. You say that you had this service done on three separate dates and this should not be applying copayments. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for each Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility and a $25 copayment for each specialist visit for Medicare-covered benefits. You have been asked to pay a $125 copayment for the tissue transfer and a $25 copayment for the office visit. The tissue transfer falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The 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 the tissue transfer provided on November 11, 2020 and the office visit provided on November 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 9, 2021.
You asked the Plan to pay for the ambulance services. You say that 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 February 9, 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 services provided on February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc injection services.
You asked the Plan to pre-approve the Genvisc injection services. You say that the clinical information provided supports the need for the injection services in dispute. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that Genvisc injections will not be repeated within six months' time
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 Genvisc injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found it has not been 6 months since the previous course of injections. 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 Genvisc injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc injection services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee from May 11,
2020, to May 21, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request.
The Plan says the Medicare data base shows the enrollee in hospice status from April 15, 2020, through May
10, 2020, and May 22, 2020, through May 27, 2020. In accordance with Medicare guidelines, the provider
needs to bill Original Medicare, using the proper modifiers, for services rendered from May 22, 1010, to May
21, 2020. Per the regulations above, the member's claim would be covered under Original Medicare as it is
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in
which hospice is revoked. It is the provider's responsibility to verify the member's coverage before rendering
services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for
physician services provided to the enrollee from May 11, 2020, to May 21, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc.
You asked the Plan to pre-approve Monovisc. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Monovisc. Our reviewer says that the medication is not medically necessary. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drug(s). There is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary resin partial denture base repair (D5612)
provided on January 25, 2021.
You asked the Plan to pay for the maxillary resin partial denture base repair. You say that you believe this
service should be covered. The Plan denied your request. The Plan says this service is not a covered benefit
under your dental plan.
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 maxillary resin partial denture base repair (D5612) provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Medicare-covered eye exam provided on February 3, 2021.
You asked the Plan to waive the copayment for the Medicare-covered eye exam. The Plan denied your request. The Plan says the claim processed as a Medicare-covered vision exam and not a routine vision exam appropriately.
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 $40 copayment for vision care, Medicare-covered exams.
You have been asked to pay $40 copayment for the Medicare-covered eye exam. The Medicare-covered eye exam falls within the vision care, Medicare-covered exam 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 a Medicare-covered eye exam provided on February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four periodontal scalings and root planings (D4341) provided on December 14, 2020, and December 21, 2020.
You asked the Plan to pay for the scalings and planings. You say that you went to the dentist for a regular cleaning, but received a deep cleaning which the provider was not authorized to do. The Plan denied your request. The Plan says this service is not included on your plan benefit schedule. The Plan also says that you signed a treatment plan with the provider agreeing to the treatment.
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 periodontal scalings and root planings (D4341) provided on December 14, 2020, and December 21, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 14,
2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says due to the enrollee's hospice status at the time of service, this claim should be submitted
to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for
physician services provided to the enrollee on April 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 3, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 had network providers available who could have provided 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 for the services provided by an out-of-network provider on February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth per quadrant (D4341) and gingival irrigation - per quadrant (D4921) provided February 4, 2021.
You asked the Plan to pay for the periodontal scaling and root planing and gingival irrigation. You say that you were not informed that the services were not covered prior to receiving them. The Plan denied your request. The Plan says these services are not covered under your dental 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 periodontal scaling and root planing - four or more teeth per quadrant (D4341) and gingival irrigation - per quadrant (D4921) provided February 4, 2021.