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

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and adult dental cleaning services (D1110) provided on July 30, 2020.
You asked the Plan to pay for the periodic oral evaluation and the adult dental cleaning services. You say that you were not aware that your benefits had changed. The Plan denied your request. The Plan says you have exhausted your benefit for these dental services for 2020.
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 periodic oral evaluation and the adult dental cleaning services once every calendar year. We looked at the file and Medicare rules. The file indicates that you last received these services in January 2020 and therefore exhausted your benefit for 2020. Based on this information, we decided that the Plan's rules for coverage of the periodic oral evaluation and the adult dental cleaning services have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and adult dental cleaning services (D1110) provided on July 30, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Planhasto pay forinpatient admission to an acute care hospital.You asked the Planto pay foracute inpatient hospital care. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthe clinical information provided does not meet medical necessity.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 supports that the criteria forinpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two 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 been met.Therefore, we decided that the Planhas to pay forinpatient admission to an acute care hospital.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from
June 13, 2020 to June 15, 2020.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you feel you should not
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan
denied your request. The Plan says you received inpatient hospital care on the dates of service at issue in this
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. The Plan says that
cost share for inpatient hospital care is not eligible for copay waiver.
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
copayment per day for days 1-4 for Inpatient Hospital Care.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received inpatient
hospital care from June 13, 2020 to June 15, 2020. You have been asked to pay a $395 copayment per day for
days 1-2, totaling $790. The inpatient hospital care falls 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 copayment for the inpatient hospital care provided from June 13, 2020 to
June 15, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 11, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is no
medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been
documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services provided on February 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forincontinence supplies.You asked the Plan to pay forincontinence supplies. You say that you are looking for a corrected denial code.The Plan denied your request. The Plan says incontinence supplies are not a Medicare benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pay forincontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 14, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says an
authorization is required to be seen by an out-of-network provider.
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
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services provided on September 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean exception to the 50 mile limit for routine transportation for the enrollee.You asked the Plan to pre-approveexceptions to supplemental benefits. You say that the member requires additionalmileage to get to medical appointments.The Plan denied your request. The Plan says that the service is a covered benefit but members request exceeds mileage limit.Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits they are not required to do so. Medicare does not provide exceptions to supplemental benefits.Therefore, we decided that the Plan does not have to pre-approvean exception to the 50 mile limit for routine transportation for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe cataract surgeries provided from August 13, 2020, to September 10, 2020.You asked the Plan to waive the copayments forthe cataract surgeries. You say that you did not know there was a copayment for your cataract surgeries. 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 withthe Plan clearly says that you must pay a $250 copayment for each in-network Medicare-covered ambulatory surgical center visit. You have been asked to pay a $250 copayment for each of the cataract surgeries. The cataract surgeries fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 forthe cataract surgeries provided from August 13, 2020, to September 10, 2020.Your complaint about the Plan'sbenefit structure 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for duplex scan of lower extremity arteries or arterial bypass
grafts (93925) provided August 28, 2020.
You asked the Plan to pay for the duplex scan. You say that please reprocess this claim for payment as a
separate and distinct procedure performed by a separate provider. The Plan denied your request. The Plan says
the diagnoses billed was not consistent with the service performed.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. There are certain diagnosis codes that support the medical necessity of the duplex
scan of extremity arteries. CPT code 93925 was billed with diagnoses code R60.0 (Localized edema) which is
not listed as an acceptable diagnosis code.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the duplex scan have not been met. Therefore, we decided that the Plan does not have to pay for
duplex scan of lower extremity arteries or arterial bypass grafts (93925) provided August 28, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment fordebridement provided on February 5, 2020.You asked the Plan to waive the copayment fordebridement. You say that a copayment already applied to podiatry services and you should not be responsible for an additional copayment for debridement.The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $35 copayment for podiatry services. Podiatry services include diagnosis and the medical or surgical treatment of injuries and diseases of the feet.You received debridement on February 5, 2020. Debridement is considered a surgical procedure and is included under podiatry services. Therefore, you cannot be charged an additional copayment for debridement. The Plan says you must pay a $35 copayment for debridement. Based on the Plancontract, however, debridement is included under podiatry services and is not subject to separate cost-sharing charges.Therefore, we decided that the Plan has to waive the copayment fordebridement provided on February 5, 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 toopen the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe provision of test materials and equipment for home INR monitoring (G0249) provided from January 11, 2020 to August 11, 2020.You asked the Plan to waive the coinsurance forthese items. You say that you should only have to pay one copay per twelve strip order.The Plan denied your request. The Plan says that the coinsurance 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 20% coinsurance for Durable Medical Equipment (DME) and Related Supplies. You have been asked to pay a 20% coinsurance for these items. These items fall within the Durable Medical Equipment (DME) and Related 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 coinsurance forthe provision of test materials and equipment for home INR monitoring (G0249) provided from January 11, 2020 to August 11, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan provided on August 17, 2020.
You asked the Plan to pay for the duplex scan. The Plan denied your request. The Plan says this service
requires prior authorization for services provided by non-participating providers.
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
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 a duplex scan provided on August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for sterile needles provided on February 18, 2020.
You asked the Plan to pay for needles, sterile (A4215). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the service code A4215, needle, sterile, any size is excluded by Medicare per the National Correct Coding Initiative policy and therefore not payable by Medicare.
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, we have confirmed that code A4215 is non-covered by Medicare. We looked at the file and Medicare rules. The needles are statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of needle, sterile (A4215) have not been met. Therefore, we decided that the Plan does not have to pay for sterile needles provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on August 4, 2020.You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are 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 providerwith the Plan. The Plan did not pre-approve the servicesat 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 nurse practitioner services provided on August 4, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health care provided to the enrollee on March 20, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 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 foroutpatient mental health care provided to the enrollee on March 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on August 11, 2020.
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the dental provider has opted out of Medicare.
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 dental
services provided on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 10, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are 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 did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 10, 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 you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 was admitted to the hospital due to multiple injuries following a serious
car accident. The enrollee was found to have injuries to her chest, brain and her internal organs and have
required a lengthy stay in the hospital. The enrollee's hemodynamically and neurologically stable only
requiring only a small amount of oxygen through a nasal cannula. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are
no services available at the LTACH that the enrollee requires that are not available at the health care setting
being offered by the health plan.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral-complete
series of radiographic images (D0210), and the cleaning (D1110) rendered by the out of network
(OON) provider on May 23, 2019.
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 the services were rendered by an out of
network provider, without 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 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 comprehensive oral evaluation (D0150), intraoral-complete series of
radiographic images (D0210), and the cleaning (D1110) rendered by the out of network (OON) provider on
May 23, 2019.