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

We decided that the Plan does not have to pay for the periodic oral evaluations, prophylaxes, first intraoral periapical x-ray, additional intraoral periapical x-ray, and bitewings provided on August 15, 2019 and February 20, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluations, prophylaxes, first intraoral periapical x-ray, additional intraoral periapical x-ray, and bitewings. You say that you have been with this Plan for years. You also say that this is the first time that these services have been denied. The Plan denied your request. The Plan says you received services from a non-contracted provider. The Plan also says that services rendered by an OON provider are not covered.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluations, prophylaxes, first intraoral periapical x-ray, additional intraoral periapical x-ray, and bitewings provided on August 15, 2019 and February 20, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the audiology visit provided on March 13, 2020. You asked the Plan to waive the coinsurance for the audiology visit. You say that you went for a primary care visit. You say that you paid your copayment but received an additional bill. The Plan denied your request. The Plan says 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 20% of the cost for each outpatient hospital visit. You have been asked to pay $36.87, which is 20% of the allowed amount for the audiology visit. The allowed amount is $184.37 (20% x $184.37 = $36.87). The audiology visit falls within the "Outpatient hospital services" benefit category. The records show that the visit was for audiology services provided by the hospital. 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 the audiology visit provided on March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the office visit you had on February 5,
2020.
You asked the Plan to adjust the copayment. You say that you have always had a $10 copayment. The Plan
denied your request. The Plan says you are responsible for the $30 copayment.
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 $30
copayment for services obtained from an out-of-network primary care provider.
Review of the file shows that you had an out-of-network office visit on February 5, 2020. You have been asked
to pay a $30 copayment for the visit. The visit falls within the out-of-network physician 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 adjust the copayment for the office visit you had on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair (E1270).
You asked the Plan to pre-approve the wheelchair. You say that the wheelchair is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that manual wheelchairs are covered when medically necessary. 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 wheelchair. Our reviewer says that in this case a wheelchair is not medically necessary. Our physician reviewer found the records show that the enrollee's mobility needs within the home are already met by a front-wheeled walker.
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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair (E1270).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services (A0432) provided December 26, 2019.
You asked the Plan to pay for the paramedic intercept services. You say that you do not feel you should be responsible for these charges. Someone in the home called 911 because you became ill and needed emergency medical treatment The Plan denied your request. The Plan says this service is not a covered benefit under Medicare or the Plan.
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 in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services (A0432) provided December 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services you received on February 18, 2020.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the copayment.
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 services provided at a specialist's office. Review of the file shows that you were provided specialist services on February 18, 2020. You have been asked to pay a $40 copayment for the services. The services fall within the physician services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the services you received on February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that a LTACH admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.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 that ongoing care needs include hemodialysis, surveillance laboratory studies, transfusions as indicated, nutritional support, and therapy services. The documentation does not support that theenrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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-approvelong-term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ostomy supplies provided on June 14, 2019. You asked the Plan to waive the deductible for the ostomy supplies. You say that you were informed the provider was out-of-network after the supplies were sent. You say that if you had known you would have used a different provider. The Plan denied your request. The Plan says the deductible applied correctly. 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 your out-of-network (POS) deductible is $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered out-of-network (POS) medical services. Until you have paid the out-of-network deductible amount, you must pay the full cost of your covered out-of-network services. The item or service you asked the Plan to waive the deductible for falls within the "Prosthetic devices and related supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 out-of-network (POS) deductible applies prosthetic devices and related supplies. This cost sharing is a contractual obligation that had not been met at the time the ostomy supplies was received on June 14, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the ostomy supplies provided on June 14, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 home health nursing visits. 
 
You asked the Plan to pre-approve home health nursing services. The Plan denied your request. The Plan says you no longer have further skilled nursing needs. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
The file shows that 10 home health nursing visits were requested. The plan has agreed to pre-approve 3 visits. 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 remaining home health nursing services. Our physician reviewer found that the enrollee was admitted to the acute hospital with septic arthritis. He completed IV antibiotics. The enrollee does not have documented skilled nursing needs. Therefore, the remaining nursing visits are not medically reasonable and 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 home health nursing have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 home health nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services and x-rays provided on December 5, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for physician services and x-rays. You say that it was your error that authorization was not requested. You say that you would like retro authorization for this. 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 has network providers available who can provide 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 physician services and x-rays provided on December 5, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service you had hurt your back and you laid in your chair. You say that you couldn't move and by the time your wife had gotten home your sugar levels had dropped very low. You stated that your wife had found you completely out of it and you were unable to be controlled or convinced to eat and drink something. Your wife decided to call 911 for help because she couldn't control you. You say that the responders got your sugar levels back up and stayed with you until you were able to function again. You stated that the services were necessary because your wife had no other choice and it was a life or death situation. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 18, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Chest X-ray (71046) provided January 16, 2020. You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied your request. The Plan says the claim did not include a valid diagnosis code for the place of service. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 71046 is not supported in the medical record. Specifically, "Z" diagnostic codes must be accompanied by a valid primary diagnosis when billed in the outpatient hospital setting. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a Chest X-ray (71046) provided January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 30, 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. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation for procedure codes G0483, 80307, 80157, 80177, 80201, 80159 and 80173. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 31, 2020. You asked the Plan to pay for the physician's services. 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 physician's services provided on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on June 30, 2018. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until February 21, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on June 30, 2018.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric services provided on December 19, 2019 to March 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for psychiatric services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referral on fire expired on June 13, 2019.
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 has network providers available who can provide 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 psychiatric services provided on December 19, 2019 to March 24, 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 IRF admission and services. You asked the Plan to pre-approve IRF care. You say that the enrollee requires 3 hours of therapy a day provided by a multidisciplinary team. The Plan denied your request. The Plan says the enrollee does not require a high-level of physician supervision with therapy services in an inpatient setting. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 physician reviewer found that the enrollee is at moderate assist for bed mobility, transfers, and walking using a rolling walker. She is at moderate assist for activities of daily living. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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: Partially Favorable

We decided that the Plan has to reduce the copayment for a SNF stay. We decided that the Plan does not have to reduce the copayment for a SNF stay.
You asked the Plan to reduce the copayment for a SNF stay. You say that you were under the impression that you would not owe a copayment. The Plan says that the claims were processed correctly and you are being charged the correct amount.
We decided that the Plan has to reduce the copayment for a SNF stay from $4,245 to $1,424.
You had a SNF stay from February 1, 2020 to February 29, 2020. You cannot be charged a copayment for days 1-20 (February 1, 2020 to February 20, 2020). You are responsible to pay a copayment for days 21-28 (February 21, 2020 to February 28, 2020). $178 (copayment) x 8 (SNF days) = $1,424. Therefore, we decided that the Plan has to reduce the copayment for a SNF stay from $4,245 to $1,424.
We also decided that the Plan does not have to reduce the copayment for a SNF stay to the amount you requested.
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 $0 copayment per day for days 1-20 and a $178 copayment for days 21-100 for a SNF stay. You had a SNF stay from February 1, 2020 to February 29, 2020. You are not being charged a copayment for days 1-20 (February 1, 2020 to February 20, 2020). You are responsible to pay a copayment for days 21-28 (February 21, 2020 to February 28, 2020). $178 (copayment) x 8 (SNF days) = $1,424. Therefore, we decided that the Plan does not have to reduce the copayment for a SNF stay.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on February 14, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the Plan.
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 diagnostic radiology services provided on February 14, 2020.