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

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
You asked the Plan to pre-approve the additional non-emergency transportation. You say that you need additional trips to continue with your therapy treatment. The Plan denied your request. The Plan says you have exhausted your 2021 transportation benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 50 one-way, non-emergency trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional trips.
You asked the Plan to pre-approve additional trips. You say that your vision is decreasing drastically. You say that you had eye removal surgery recently. You say that you need to continue to see your doctor to make sure you are progressing. You also say that you do not have family members to help you. The Plan denied your request. The Plan says that up to 48 one-way rides per year to other health care related locations. The Plan also says that once the benefit limit of 48 one-way rides to other health care related locations has been reached, we are unable to approve additional coverage outside of your covered benefits.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of up to 48 one-way rides per year to other health care related locations trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional trips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided June 10, 2020.

You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the CPT code billed.

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 97110 is not supported in the medical record. Specifically, the record shows this service was provided in the home health setting. There is a more appropriate CPT code that describes the services at issue in the home setting (G0157). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the enrollee on February 4, 2021.

You asked the Plan to pay for this testing. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says this type of testing is not covered by Medicare.

The Plan must follow Medicare rules. The Medicare rules specifically state this testing is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the enrollee on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extracorporeal shock wave therapy (ESWT).
You asked the Plan to pre-approve the therapy. You say that this is medically necessary for treatment of erectile dysfunction. The Plan denied your request. The Plan says this is not currently U.S. Food and Drug Administration (FDA)-approved for treatment of erectile dysfunction.
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 the therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the most current urology guidelines, this therapy should be considered investigational and only performed in the context of a clinical trial. Furthermore, ESWT is not consistently the standard of care nor supported by current literature. 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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve extracorporeal shock wave therapy (ESWT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on April 20, 2021.
You asked the Plan to pay for the consultation. You say that you asked for an evaluation and cleaning when
scheduling this visit. You also say that you did not know there would be additional codes that would not be
covered by the Plan. The Plan denied your request. The Plan says this service is not a covered benefit under
your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
consultation (D9310) provided on April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331), and
endodontic procedure (D3999), or pay more for the crown (D2740), prefabricated post and core in addition to
crown (D2954), endodontic therapy (D3320), and consultation (D9310) provided on October 4, 2018.
You asked the Plan to pay for the treatment of root canal obstruction, and endodontic procedure, and to pay
more for the crown, prefabricated post and core, endodontic therapy, and consultation. You say that you would
like these services to be covered due to the poor work the provider rendered you. The Plan denied your request.
The Plan says the treatment of root canal obstruction, and endodontic procedure are not covered services. The
Plan also says that copayments are a contractual obligation and cannot be waived.
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, treatment of root canal obstruction
(D3331) and unspecified endodontic procedure (D3999) are not among those covered under this benefit. The
contract says that you are responsible for a $250 copayment for a crown (D2740), a $65 copayment for a
prefabricated post and core in addition to crown (D2954), a $225 copayment for endodontic therapy (D3320),
and a $50 copayment for a consultation (D9310). Therefore, we decided that the Plan does not have to pay for
the treatment of root canal obstruction (D3331), and endodontic procedure (D3999), or pay more for the crown
(D2740), prefabricated post and core in addition to crown (D2954), endodontic therapy (D3320), and
consultation (D9310) provided on October 4, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral cancer screening (D0431) provided on April 7, 2021.
You asked the Plan to pay for the oral cancer screening. You say that you were not aware that this service was not covered. You also say that you were not advised that you would be responsible for any amount. The Plan denied your request. The Plan says this service is not covered by your plan. The Plan also says that you signed a treatment plan with the provider acknowledging that the oral cancer screening was not covered, and you would be responsible for the charge.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral cancer screening (D0431) provided on April 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the nuclear stress test you had on March
19, 2021, and the cardiovascular stress test you had on March 25, 2021.
You asked the Plan to waive the copayments for the stress tests. You say that the treadmill stress test should
have been done at the same time as the nuclear stress test, which would have avoided the second copayment.
The Plan denied your request. The Plan says you were charged these copayments 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 $150
copayment for each advanced imaging service (including stress tests).
You have been asked to pay a $150 copayment for each of the stress tests. You had two stress tests, so two
copayments apply. 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 for the nuclear stress test you had
on March 19, 2021, and the cardiovascular stress test you had on March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft (D4263).
You asked the Plan to pre-approve the bone replacement graft. You say that this is a necessary part of the implant procedure, and you do not have enough money to pay for it. The Plan denied your request. The Plan says this service is not covered under your benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft (D4263).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement of nails by any method, 1-5 (11720) and
trimming of dystrophic nails, any number (G0127) provided January 6, 2021.

You asked the Plan to pay for the podiatry services. You say that the price is way too high for the little minutes
you were in the office. you doctor recommended the services to you after surgery. You feel that the services
should be covered. The Plan denied your request. The Plan says the service is not covered under the Plan
benefits.

The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or
feet or have fungal nails. The health plan contract on page 82 specifically says that unless you meet the
qualification for under Original Medicare for diabetic foot care, there is no coverage for any routine foot care,
regardless of care setting, including but not limited to toenail trimming, nail debridement, and/or callous or
corn treatment.

Records do not show that any of these conditions are present. The services you are asking the Plan to pay for
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the
podiatry services have not been met. Therefore, we decided that the Plan does not have to pay for debridement
of nails by any method, 1-5 (11720) and trimming of dystrophic nails, any number (G0127) provided January
6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on February 19, 2021.
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 procedure code 00811 is not supported.
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 00811 is anesthesia for lower intestinal endoscopic
procedures, endoscope introduced distal to duodenum; not otherwise specified.
We find that CPT code 00811 is not supported in the medical record. Specifically, the records show that the
procedure was discontinued. 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 anesthesia services
rendered on February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on February 1, 2021, to March 15, 2021.
You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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 Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $259.68. The total amount you are being asked to pay is $51.94 ($259.68 x 20% = $51.94). The correct coinsurance has been applied to the injections that were provided.
An injection falls within the Medicare Part B prescription drugs 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 an injection provided by participating provider February 1, 2021, to March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on March 30, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were referred to the neurologist and assumed the visit was approved. 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 $40 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted by Medicare rules). You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The record shows the visit was approved since the claim was not denied.
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 specialist office visit provided on March 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for laboratory services provided to the enrollee on March 26, 2020.
You asked the Plan to pay this claim. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on March 26, 2020 and received by the lab on March 30, 2020.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to an issue with the POS codes reported. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on March 19, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on March 19, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit (99214) rendered by the out-of-network (OON) provider on August 17, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the service was rendered by an out of network provider, without prior authorization.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, an Evidence of Coverage booklet that indicates the Plan contract was included for review for a different calendar year than the service provided. Therefore, we decided that the Plan has to pay for the office visit (99214) rendered by the out-of-network (OON) provider on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on
April 12, 2021.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you've been going to
this dentist for years and was not aware he is not in-network. You say that it is a hardship to learn you may be
responsible for the entire bill. The Plan denied your request. The Plan says the provider is out-of-network with
the Plan and no payment can be issued.

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, out-of-network dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
periodic oral evaluation and prophylaxis provided on April 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on April 16, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the evaluation and management. You say that the service was denied for no authorization. You say that you have applied for in network status and were denied without cause. The Plan denied your request. The Plan says prior authorization was not obtained before the services were rendered to the enrollee.

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. Although the enrollee's plan has a Point of Service (POS) benefit, authorization is still required to see any out of network providers. 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 (99308) provided on April 16, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 31, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the provider provides acute visits to the enrollee at the nursing home. You say under traditional Medicare, this claim would not need authorization. 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 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
March 31, 2021 by an out-of-network (OON) provider.