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

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 16, 2021 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says the services were rendered by an OON provider. The Plan also says that 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 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 subsequent nursing facility care provided on February 16, 2021 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on May 11, 2020 to May 28, 
2020 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-
of-network with the Plan and these tests were not ordered by an in-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 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 testing provided on May 11, 2020 to 
May 28, 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 intraoral complete series of radiographic images (x-rays) (D0210), provided on January 13, 2021.
You asked the Plan to pay for intraoral x-rays complete series. You say that the service should be covered. The Plan denied your request. The Plan says you have exhausted your Plan 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. Specifically, you have already received this service within the past five years. This means the service is not a covered benefit. Therefore, we decided that the Plan does not have to pay for intraoral complete series of radiographic images (x-rays) (D0210), provided on January 13, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2025) provided on February 27, 2021.
You asked the Plan to pay for the deluxe frames (V2025). The Plan denied your request. The Plan says Original Medicare is not required to cover the luxury frames and neither is the health Plan.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, Medicare rules and the Plan's rules. The file shows that the Plan does not provide
coverage for deluxe frames. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2025) provided on February 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on January 4, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that you did not know about the copayment for physical therapy. You say that if you knew there was a $40 copayment you might not go again. 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 $40 copayment for Medicare-covered outpatient rehabilitation services.
You have been asked to pay a $40 copayment for the physical therapy visit. Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided on January 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray coded 71045 provided on March 16, 2021.
You asked the Plan to pay for the chest x-ray. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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 71045
for the chest x-ray has a bundled relationship with code 71046 and cannot be paid as billed. Code 71046 was
billed on the same date of service by a physician of the same specialist in the same billing group. This code
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been
met. Therefore, we decided that the Plan does not have to pay for the chest x-ray coded 71045 provided on
March 16, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and the routine venipuncture (36415) rendered by the out-of-network (OON) provider on February 15, 2021.
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 office visit (99214) and the routine venipuncture (36415) rendered by the
out-of-network (OON) provider on February 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient therapy provided by an out-of-network provider on October 17, 2020.
You asked the Plan to pay for outpatient therapy. You say that it is expensive to pay for massage therapy. You say that you would not have gone to the visit if you knew it would not be covered. The Plan denied your request. The Plan says prior authorization is required for any services provided by a non-contract 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 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 outpatient therapy provided by an out-of-network provider on October 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on March 4, 
2021. 
 
You asked the Plan to pay for the dental service. You say that you are trying to get your bottom dentures with a 
different provider. You also say that your plan will not pay for the exam. The Plan denied your request. The 
Plan says 1 comprehensive oral exam is covered every 3 years. The Plan also says that the frequency limit has 
been exceeded. 
 
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 and comprehensive oral exam is listed 
as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive 
oral exam that you received on October 1, 2020. Therefore, we decided that the Plan does not have to pay for 
the comprehensive oral exam (D0150) provided on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve office visit. You say that it is imperative that the enrollee see a specialist who can properly assess her condition. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network hepatology specialist.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) for the enrollee.
You asked the Plan to pre-approve these services. You say that the patient has significant urgency, frequency and urgency incontinence that has been refractory to medications and behavioral medications. The Plan denied your request. The Plan says that the enrollee does not meet the rules for medical necessity because the enrollee has two anatomic causes of obstruction affecting incontinence/urinary symptoms.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The medical records indicate that the enrollee has neurologic disease (Lewy body dementia) and bladder outlet obstruction which exclude neuromodulation as a treatment option. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these servicees. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve an incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's needs have been and are currently custodial.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a primary care telehealth office visit provided on February 13, 2021.
You asked the Plan to waive the copayment for primary care visit. You say that you never had a visit with this provider on this day and feel that they may be mixing someone else up with you. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $10 copayment for primary care telehealth visit. The record shows that you received a primary care telehealth visit on this date of service, therefore the primary care copayment applies to this claim.
You have been asked to pay $10 copayment for primary care visit. Primary care 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 a primary care telehealth office visit provided on February 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ground mileage (A0425), and basic life support, emergency, ambulance transportation (A0429) provided on February 7, 2021.
You asked the Plan to pay for the transportation services. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of vehicle.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the transportation services. Our reviewer says that the ambulance services are not medically necessary. Our physician reviewer found the provided documentation do not indicate that the enrollee had presenting symptoms that meet prudent layperson criteria for emergency care. The reviewer found that the documentation does not show that other means of transportation such as wheelchair van or stretcher van would be contraindicated for the enrollee as she was stable and able to sit. The reviewer found that the enrollee did not require the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The reviewer also found that the documentation does not indicate that the transportation services were medically reasonable or necessary. 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 transportation services have not been met. Specifically, the record shows that the enrollee did not require the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. Therefore, we decided that the Plan does not have to pay for ground mileage (A0425), and basic life support, emergency, ambulance transportation (A0429) provided on February 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on March 24, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that this was a pre-operative visit and 
there should not be a copayment. The Plan denied your request. The Plan says you have been asked to pay the 
correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for each covered test or consultation in an outpatient location with your PCP or other primary care 
provider.

You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/ 
Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the 
contract which indicates a copayment would be waived for an office visit if performed as a pre-operative 
appointment to a surgical procedure. 
 
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 office visit provided on March 24, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that a sub acute rehabilitation admission for physical therapy and occupational therapy will help increase conditioning and ambulation for the enrollee's eventual discharge to her home. The Plan denied your request. The Plan says that the enrollee does not require daily skilled therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
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 the enrollee has rehabilitation needs that necessitate daily medical oversight. 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 the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee does require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued care at a Skilled Nursing Facility (SNF) provided from January 15, 2020, to February 13, 2021.
You asked the Plan to pay for the continued stay. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require any skilled services on the dates of service in this case.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the continued stay. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 continued stay have not been met. Specifically, the enrollee did not receive daily skilled services. Therefore, we decided that the Plan does not have to pay for the continued care at a Skilled Nursing Facility (SNF) provided from January 15, 2020, to February 13, 2021.