Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate upper denture (D5130) provided on January 26, 2021.
You asked the Plan to pay for the dental service. You say that you did not see anything in your book or benefits online that you had done that would be denied. You also say that you do not understand why this service was denied. The Plan denied your request. The Plan says interim upper denture is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 immediate upper denture (D5130) provided on January 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide or certified nurse assistant, providing care in the home; per hour (S9122) provided from August 16, 2020, to November 21, 2020.

You asked the Plan to pay for the home health services. You say that these services should be covered.The Plan denied your request. The Plan says the provider in this case is not a certified Medicare provider. The Plan says that payment cannot be made for services performed by a provider that is not a certified Medicare provider. The Plan also says that custodial care is not covered.

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 home health services have not been met.Therefore, we decided that the Plan does not have to pay for the home health aide or certified nurse assistant, providing care in the home; per hour (S9122) provided from August 16, 2020, to November 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The
Plan denied your request. The Plan says you do not meet Medicare criteria for the requested CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day, does not use insulin with at least three daily injections, and does not
require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this
information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided
that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 14, 2020 by an out of network provider.
You asked the Plan to pay for the office visit. You say that you did not know you were not a contracted provider. The Plan denied your request. The Plan says you did not request 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit provided on December 14, 2020 by an out of network provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the private-duty nursing services rendered on May 12, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that the services of a private-duty nurse are not covered. We looked at the file and Medicare rules. The services at issue are private-duty nursing. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the private-duty nursing services rendered on May 12, 2020.
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 October 1, 2020 to October 15, 2020.
You asked the Plan to pay for home health services. 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. 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. The rules say the Type of Bill is a required data element needed to submit a claim under home health PPS. This 4-digit code gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit indicates the sequence of this bill in this particular episode of care. The types of bill accepted for HH PPS requests for anticipated payment are either 7, 8, or 9 as defined above. HHAs must submit HH PPS claims with the 4th digit of "9." Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 1, 2020 to October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided
on January 25, 2021.
You asked the Plan to pay for a comprehensive periodontal evaluation. You say that you think the Plan should
cover this service. The Plan denied your request. The Plan says this service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a
comprehensive periodontal evaluation (D0180) provided on January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on September 3, 2020.
You asked the Plan to pay for the durable medical equipment. 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.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on December 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for home health services. You say that these services were provided in an assisted living facility. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 home health services provided on December 4, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you need this level of care. The Plan denied your
request. The Plan says the denial of authorization for IRF service is correct.
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. While the 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with progressive weakness. She is now medically stable with no complex nursing or rehabilitation needs. She does 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. There is not a reasonable expectation that the enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 14, 2020.
You asked the Plan to pay for the laboratory services. 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.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare
rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not
have to pay for the laboratory services provided on December 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided from December 9, 2020, through December 14, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says authorization was not obtained prior to the services being rendered.
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 subsequent nursing facility care provided from December 9, 2020, through December 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility services provided on
December 8, 2020.
You asked the Plan to pay for the subsequent nursing facility services. The Plan denied your request. The Plan
says authorization was not obtained prior to the services being rendered.
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 subsequent nursing facility services provided on
December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the periodic oral evaluation (D0120), panoramic radiographic image (D0330), bitewings - four radiographic images (D0274) and prophylaxis - adult (D1110) provided November 12, 2020.
You asked the Plan to provide additional payment for the dental exam, panoramic x-rays, bitewing x-rays and dental cleaning. You say that you were told before you signed up for your plan that services at your dental office were covered and you believe the Plan should pay the full amount. The Plan denied your request. The Plan says since your services were received from an OON provider, you are responsible for the difference between the maximum allowed amount paid by the Plan and the total amount charged by the OON provider.
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 exam, panoramic x-rays, bitewing x-rays and dental cleaning when the services are medically necessary and reasonable. The Plan will pay dental claims up to the MAC. You may be billed by an OON provider for any amount greater than the MAC payment. We looked at the file and Medicare rules. In this case your received dental services from an OON provider. The Plan paid the MAC for the services. Based on this information, we decided that the Plan does not have to provide additional payment for the periodic oral evaluation (D0120), panoramic radiographic image (D0330), bitewings - four radiographic images (D0274) and prophylaxis - adult (D1110) provided November 12, 2020.
Your complaint about potentially receiving misinformation at the time of enrollment and request for an exception based on limited use of dental services due to COVID-19 concerns in the year 2020 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided from December 7, 2020, through December 20, 2020.
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care provided from December 7, 2020, through December 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on February 2, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that no referral could be provided because the enrollee had not been seen by the PCP for a long time. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the nursing facility care provided on February 2, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a
participating provider on October 9, 2020.
You asked the Plan to waive the copayment for specialist services. You say that you do not agree with the
copayment that was applied. The Plan denied your request. The Plan says the correct copayment has been
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 $35
copayment for physician/practitioner service/specialist.
You have been asked to pay a $35 copayment for specialist services. The correct copayment has been applied
to the services that were provided. Specialist services fall within the physician/practitioner service/specialist
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 specialist services provided by a
participating provider on October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient dialysis services provided by a participating provider on October 3, 2020, to October 31, 2020.
You asked the Plan to waive the coinsurance for outpatient dialysis services. You say that you do not agree with these charges for at home dialysis services. The Plan denied your request. The Plan says the correct coinsurance has been 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 20% coinsurance for services to treat kidney disease/in-network/outpatient dialysis treatments. You have been asked to pay a 20% coinsurance of the allowed amount for outpatient dialysis services. The total allowed amount is $3,625. The total amount you are being asked to pay is $725 ($3,625 x 20% = $725). Outpatient dialysis services falls within the services to treat kidney disease/in-network/outpatient dialysis treatments 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 coinsurance for outpatient dialysis services provided by a participating provider on October 3, 2020, to October 31, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on September 14,
2020.

You asked the Plan to pay for the evaluation and management service. You say that the service was medically
necessary. The Plan denied your request. The Plan says the enrollee'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. The Plan also says 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 date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the subsequent hospital care provided on September 14, 2020.