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

We decided that the Plan does not have to waive the coinsurance for the outpatient hospital services provided
from October 9, 2019 to October 10, 2019.
You asked the Plan to waive the coinsurance for the outpatient hospital services. You say that you would like
the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient
hospital services on the dates of service at issue in this appeal. The Plan says the correct coinsurance has
applied per your contract with the Plan.
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 Medicare-covered surgery or other services provided to you at an outpatient hospital, including
but not limited to hospital or other facility charges and physician or surgical charges.
We looked at the file, the Plan's contract and Medicare rules. The file shows you received outpatient hospital
services from October 9, 2019 to October 10, 2019. You have been asked to pay a 20% coinsurance for the
outpatient hospital services, totaling $4660.10. However, you only needed to pay $3262.54 in order to meet
your $6700 out-of-pocket maximum for the 2019 benefit year. The outpatient hospital services fall within the
Outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the outpatient
hospital services provided from October 9, 2019 to October 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of periapical x-rays (D0210) provided on January 24, 2020.
You asked the Plan to pay for the dental service. You say that the x-rays should have been covered. You say that you have not had x-rays in over 10 years. You also say that at least part of the cost should have been covered. The Plan denied your request. The Plan says the complete series of periapical x-rays are not 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 complete series of periapical x-rays is not among those covered under this benefit. The Evidence of Coverage specifically states that bitewing x-rays are the only x-rays that are covered by the Plan. Therefore, we decided that the Plan does not have to pay for the complete series of periapical x-rays (D0210) provided on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services were requested in order to evaluate and manage the enrollee's condition. The Plan denied your request. The Plan says the enrollee does not have out of network benefits.
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 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 medical services provided on July 22, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 1, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe echocardiography provided on October 31, 2019.You asked the Plan to waive the copayment forthe echocardiography. You say that you didn't go to the hospital. You say that you should only have a $20 copayment.The Plan denied your request. The Plan says the copayment applied correctly.The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay a $100 copayment per visit. Covered services include laboratory and diagnostic tests billed by the hospital. You have been asked to pay a $99.50, which is less than the standard $100 for the echocardiography. The echocardiography falls within the "Outpatient hospital services" benefit category. The records show that the echocardiography was billed 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 copayment forthe echocardiography provided on October 31, 2019
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reimburse you for the Long IV Iron services provided on September 23, 2019.You asked the Plan to reimburse you for the Long IV Iron services. You say that you would like the Plan to reconsider your request.The Plan denied your request. The Plan says that CPT code 90120 is not a valid code.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were referred for the Long IV Iron services by a contract provider. The file does not show that the Plan provided notice that the Long IV Iron services would not be covered. Under Medicare rules, this means the Long IV Iron services are considered approved by the Plan.Therefore, we decided that the Plan has to reimburse you for the Long IV Iron services provided on September 23, 2019.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: 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 the ambulance response services should be
covered. 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 November 24, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy (97124).
You asked the Plan to pre-approve massage therapy. You say that your doctor advised you actual chiropractic
care would not be in your best interest. The Plan denied your request. The Plan says the service is not a covered
benefit.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore,
we decided that the Plan does not have to pre-approve massage therapy (97124).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on December 26, 2019.You asked the Plan to pay for the dental service. You say that you were not advised that the x-ray would not be covered. You also say that had you known the x-ray would not be covered, you would not have gotten it.The Plan denied your request. The Plan says the panoramic x-ray is not 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 panoramic x-ray is not among those covered under this benefit. The Evidence of Coverage only specifically lists bite wing x-rays as x-rays that are covered.Therefore, we decided that the Plan does not have to pay for the panoramic x-ray(D0330) provided on December 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laser procedure provided on November 6, 2019.
You asked the Plan to waive the copayment for the laser procedure. You say that there was no other option to receive the care you needed. You say that the charge isn't fair. 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 $30 copayment, after deductible, for each in-network specialist visit for Medicare-covered benefits. Covered services include medically-necessary medical care or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, walk-in clinic, (non-urgent) or any other location. You have been asked to pay a $30 copayment for the laser procedure. The laser procedure falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the laser procedure was provided in a specialist's office. 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 laser procedure provided on November 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the basic metabolic panel services coded 80047 provided on December 11, 2019. You asked the Plan to pay for the basic metabolic panel services. 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 supported by the documentation. 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, the CPT Code Manual definition of code 80047 is basic metabolic panel (Calcium, ionized) This panel must include the following: Calcium, ionized (82330) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea Nitrogen (BUN) (84520). We find that CPT code 80047 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records for the billed test. Based on this information, we decided that Medicare rules for coverage of the basic metabolic panel services have not been met. Therefore, we decided that the Plan does not have to pay for the basic metabolic panel services coded 80047 provided on December 11, 2019.
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 requires an IRF level of care. The Plan denied your request. The Plan says there are no skilled nursing or skilled therapy needs. The Plan says that the enrollee's medical condition is not complex and he does not need to be seen by a rehab doctor three times per week. The Plan says that the enrollee does not meet the guidelines for IRF services and his needs can safely be met at a lower level of care.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is not medically stable with chest pain and leukocytosis after hip and pelvic fractures. An IRF admission is not appropriate, as the enrollee cannot participate in the therapies. The criteria for coverage have not been met. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle.
You asked the Plan to pre-approve a Group 1 power operated vehicle. You say that you need a scooter. The
Plan denied your request. The Plan says the face-to-face exam did not include details for medical necessity.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
The file does not show contain a valid face-to-face documentation. This means that Medicare rules for
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a
Group 1 power operated vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair component or accessory, not otherwise specified (K0108).
You asked the Plan to pre-approve the item. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says this does not serve a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Red Corvette Drive Wheel Accent Color (K0108) is a non-standard upgrade and does not serve a medical purpose. Therefore, we decided that the Plan does not have to pre-approve wheelchair component or accessory, not otherwise specified (K0108).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS non-emergency ambulance service (A0428) and ground mileage (A0425) provided October 25, 2019.
You asked the Plan to pay for the ambulance service. You say that the enrollee was not covered under hospice on the date of service The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on October 16, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the BLS non-emergency ambulance service (A0428) and ground mileage (A0425) provided October 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prosthodontics fixed for tooth #19 and #20 (D6245) and white glass capsules for tooth #18 & #21 (D6740), for the enrollee.
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the information sent does not tell why a denture cannot be used to replace the enrollee's missing teeth.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. The information sent does not tell why a denture cannot be used to replace the enrollee's missing teeth. Therefore, we decided that the Plan does not have to pre-approve prosthodontics fixed for tooth #19 and #20 (D6245) and white glass capsules for tooth #18 & #21 (D6740), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient detoxification from November 6, 2019 to November 12, 2019.
You asked the Plan to pay for an inpatient detoxification. You say that the enrollee was at high risk for complication of alcohol withdrawal. The Plan denied your request. The Plan says this was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 an inpatient detoxification. Our reviewer says that the services at issue do not meet criteria for coverage. Our physician reviewer found it was not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. The enrollee did not have active medical issues that required acute inpatient medical care. The enrollee was alert, fully oriented, and his physical exam was normal. There were no tremors. There were no obvious signs of alcohol intoxication or withdrawal. A toxicology screen was negative. It was documented that the enrollee was medically stable. The documentation does not support that inpatient alcohol detoxification was medically necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient detoxification have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient detoxification from November 6, 2019 to November 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 30, 2019 by a noncontracted provider.
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 were rendered by a non-contracted 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 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 the medical services provided on August 30, 2019 by a non-contracted provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 15, 2019.
You asked the Plan to pay for the drug testing. 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 supported by the documentation. 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, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests were to be performed. The submitted documentation does not itemize what tests are included in the panel. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 15, 2019.