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

We decided that the Plan does not have to pay for the laboratory services provided on November 9, 2020, and
December 16, 2020, by an out-of-network provider.
You asked the Plan to pay for the laboratory services. You say that you were told on a previous call that you
had an authorization to go to an out-of-network provider while you are temporarily out of state. The Plan
denied your request. The Plan says this provider is out-of-network, the services were not referred by a network
provider and the services were not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 9,
2020, and December 16, 2020, by an out-of-network provider. 
Your complaint about being told on a previous phone call with the Plan that you had authorization to see an out-of-network provider 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay the $1,000 allowance for the hearing aids (V5261) purchased on December
21, 2020.
You asked the Plan to pay the $1,000 allowance for the hearing aids. You say that you realized you were
having difficulty hearing and had a routine hearing exam. The provider determined you were eligible for the
$1,000 hearing aid allowance provided by the Plan and are struggling to afford this extra expense after the
Plan's denial. The Plan denied your request. The Plan says that hearing aids are not covered by Medicare under
any condition.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan will pay up
to $1,000 for up to 2 hearing aids every 2 calendar years.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have been met. Therefore, we decided that the Plan has to pay the $1,000
allowance for the hearing aids (V5261) purchased on December 21, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay 50% of the allowed amount for the complete upper denture (D5110) provided on December 3, 2020.
You asked the Plan to pay 50% of the allowed amount for the dental service. You say that you had not had your previous denture replaced in more than 10 years. You say that after receiving the denial, you contacted the plan. You say that you should be responsible for 50% of the Medicare approved amount, with 1 procedure once every 5 years. The Plan denied your request. The Plan says complete 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 50% of the allowed amount for the complete upper denture (D5110) provided on December 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services received on October 27, 2020
You asked the Plan to pay for the surgery services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the surgery services received on October 27, 2020
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 November 23, 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 November 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient behavioral health services provided on March 19, 2020 to March 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the inpatient behavioral health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the inpatient behavioral health services provided on March 19, 2020 to March 25, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept transportation (A0432) received January 19, 2021.

You asked the Plan to pay for the paramedic intercept transportation. You say that you were told by the paramedic that the requested service would be covered. The Plan denied your request. The Plan says Medicare will not pay for paramedic services if the volunteer company does not have a contract with the paramedics or already bills Medicare for paramedic ambulance services.

The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. 

The Plan has confirmed that the provider at issue does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic intercept transportation (A0432) received January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for topical application of fluoride (D1206), and an extraction (D7210) provided on September 22, 2020, and December 22, 2020.

You asked the Plan to pay for topical application of fluoride, and an extraction. You say that you were told that the provider was in-network and you want the Plan to pay for these services. The Plan denied your request. The Plan says the services at issue are 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 topical application of fluoride (D1206), and an extraction (D7210) provided on September 22, 2020, and December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (80053, 85025, 80305, 84550) provided on December 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON laboratory services. You say that you did not know you are not in-network. 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 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 laboratory services (80053, 85025, 80305, 84550) provided on December 1, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on October 23,
2020.
You asked the Plan to pay for the surgical extraction. You say that you feel that you should be reimbursed 50%
of the allowed amount for what a simple extraction would be. 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, surgical extractions (D7210) are not
among those covered under this benefit. The only type of extraction covered under your plan is simple
extraction (D7140). Therefore, we decided that the Plan does not have to pay for the surgical extraction
(D7210) provided on October 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 revision of a ventriculoperitoneal shunt. 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 acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient hospital services provided from June 17, 2020, to June 20, 2020.
You asked the Plan to waive the copay for the inpatient services. The Plan denied your request. The Plan says the claim 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 a $395 copay for in-network for inpatient hospital care. You have been asked to pay a $395 copay for 3 days of inpatient services, totaling $1185. The services fall within the inpatient hospital 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 copay for the inpatient hospital services provided from June 17, 2020, to June 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital services provided from November 9, 2020 to November 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the hospital services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not payable.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the hospital services provided from November 9, 2020 to November 21, 2020 by an out of network (OON) provider.
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 2, 2020 to October 9, 2020.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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, these services require a valid type of bill for processing and payment. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 2, 2020 to October 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a stroke and was discharged home on April 30, 2021. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 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. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care for the right shoulder joint replacement (CPT code(s): 23430 and 23472).
You asked the Plan to pay for acute inpatient hospital care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the planned procedure listed under CPT codes 23472 and 23430 are not listed on the CMS Inpatient Only List. The Plan states the procedures are currently approved as an ambulatory procedure, and there is no documentation provided to support the expectation you will require a greater than two (2) midnight stay. The Plan states if you experience any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expects that your necessary hospital care (including earlier emergency department (ED) and/or observation care) will span two (2) midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for inpatient hospital care for the right shoulder joint replacement (CPT code(s): 23430 and 23472).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99201), the x-ray exam of the cervical spine (72040), and the x-ray exam of the lumbar spine (72100) provided from December 9, 2020, through December 28, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy or by Medicare.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99201), the x-ray exam of the cervical spine (72040), and the x-ray exam of the lumbar spine (72100) provided from December 9, 2020, through December 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided September 24, 2020.
You asked the Plan to pay for the durable medical equipment. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this service has denied for unlisted procedure code.
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. Review of the file shows that the proof of delivery did not include an itemize order form or invoice to indicate the specific supplies; therefore, the billed supply code cannot be verified. 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 September 24, 2020.