Persius/hicric huggingface dataset:
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 you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that 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 was admitted for chronic obstructive pulmonary disease exacerbation.
The enrollee's medical conditions are stable. The documentation does not support that the enrollee requires an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does
not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can
be met at a lower level of care.

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 pre-approve the continuation of skilled nursing facility (SNF) care.

You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care is necessary because
you do not have resources at home to provide adequate care. The Plan denied your request. The Plan says the
continuation of SNF care is not medically necessary as your needs can be met at a lower level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 the continuation of SNF care. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no
identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, you do
not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity
of service criteria for an inpatient basis in a skilled nursing facility 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 continuation of SNF care have not been met. Therefore, we decided that the
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided by an out of network (OON) provider.

You asked the Plan to pay for radiology services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is out-of-network.

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 radiology services provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for duplex scans provided on August 24,
2020.

You asked the Plan to waive the copayments for duplex scans. You say that you disagree with the charges and
feel that the Plan should be responsible for them. The Plan denied your request. The Plan says the claims were
processed correctly, and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110
copayment for each radiological diagnostic service.

You received duplex scans provided on August 24, 2020, for a total of two scans. Therefore, you are
responsible to pay a $110 copayment per each duplex scan. The total amount you owe is $205.74, which is less
than the total copayment amount.

You have been asked to pay $205.74 for duplex scans. Duplex scans fall within the outpatient diagnostic tests
and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for
duplex scans provided on August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 4).

You asked the Plan to pay for the dental services. You say that the enrollee is profoundly cognitively impaired, autistic individual who has myoclonic epilepsy and cerebral palsy. You say that the enrollee must have an appointment prior to service as it minimizes the enrollee's wait time prior to the appointment. You also say that the enrollee must have dental care under anesthesia. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services performed out of network 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, periodontal scaling and root planing is not covered when you receive this service out of network. The Evidence of Coverage clearly states that care rendered by a provider that is not part of our supplemental dental network is not covered. Additionally, the record shows that there are in network provider available. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the hearing aids purchased on July 29, 2020.

You asked the Plan to reimburse you for the hearing aids. You say that hearing aids are not a luxury item but rather a medical necessity. The Plan denied your request. The Plan says your benefit does not include the purchase of hearing aids.

The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. 

Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to reimburse you for the hearing aids purchased on July 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an IV tubing extension set (S1015) and infection control supplies (S8301).

You asked the Plan to pay for an IV tubing extension set and infection control supplies. You say that these items should be covered. The Plan denied your request. The Plan says these items were not billed with valid codes.

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 codes S1015 and S8301 are not supported in the medical record. Specifically, these codes have a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of an IV tubing extension set and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for an IV tubing extension set (S1015) and infection control supplies (S8301).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on July 30, 2020.

You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided by an out of network (OON) provider.

You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the rendering skilled nursing facility is also out-of-network.

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 skilled nursing services provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP and supplies provided by an out of network provider.

You asked the Plan to pay for the CPAP and supplies. You say that you used a tool that indicated authorization was not required. The Plan denied your request. The Plan says you did not request 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 had network providers available who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the CPAP and supplies provided by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram, routine ECG with at least twelve
leads, interpretation and report only (93010).

You asked the Plan to pay for the ECG. You say that you have attached documentation that provides details of
the services that were performed. Please review the attachments and reconsider payment of this claim The Plan
denied your request. The Plan says there is no support in the documentation to suggest an unusual circumstance
that would justify the need for two EKG interpretations during the same ER visit.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units
provided for each procedure code.

We find that two units of CPT code 93010 are not supported in the medical record. The medical record only
supports one unit of CPT code 93010. Based on this information, we decided that Medicare rules for coverage
of the ECG have not been met. Therefore, we decided that the Plan does not have to pay for the
electrocardiogram, routine ECG with at least twelve leads, interpretation and report only (93010).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay the allowance for the hearing aids purchased on August 13, 2020.

You asked the Plan to pay the allowance for the hearing aids. You say that the 2020 Annual Notice of Changes
states in and out of network there is a $1000 allowance for any model and your EOC states in or out of network
also. The Plan denied your request. The Plan says that you did not use the preferred provider.

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 does not say in clear and accurate terms
how much you should expect of an allowance for Hearing Aids.

We looked at your contract with the Plan. We see where the 2020 Annual Notice of Changes says you receive a
$1000 allowance every year for In- and Out-of-Network Hearing Aids for any model. We see where the
contract says $0 copayment for each hearing aid In- and Out-of-Network. The Plan contract does not clearly
say you must stay In Network because the language states In- and Out-of-Network services. This means that
the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that
the Plan has to pay the allowance for the hearing aids purchased on August 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 23, 2020.

You asked the Plan to pay for the ambulance services. 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 August 23, 2020. 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 provided on August 23, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management, more than thirty
minutes.

You asked the Plan to pay for the evaluation and management service. You say that the medically necessary
service was provided to the enrollee in good faith. The Plan denied your request. The Plan says the enrollee's
claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on
the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the
provider's responsibility to verify the member's coverage before rendering services and to know proper billing
procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the hospital discharge day management, more than thirty
minutes.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment (R0070)
provided on September 4, 2020.

You asked the Plan to pay for the transportation of portable x-ray equipment. You say that this is a covered
service. 

The Plan denied your request. The Plan says this is not payable with the billed place of service.
The Plan must follow Medicare rules. Medicare rules say that when a skilled nursing facility (SNF) resident
receives a portable x-ray service during the course of a Medicare-covered stay in the SNF, only the service's
professional component is a separately billable physician service under Part B. By contrast, the technical
component representing the procedure itself, including any associated transportation and setup costs, would be
subject to consolidated billing, and must be included on the SNF's Part A bill for the resident's covered stay
rather than being billed separately under Part B.

We looked at the file and Medicare rules. The service at issue was billed with place of service 31, indicating it
took place in a skilled nursing facility. Technical components, including transportation costs, are not billed
separately from the SNF stay. Based on this information, we decided that Medicare rules for coverage of the
transportation of portable x-ray equipment have not been met. Therefore, we decided that the Plan does not
have to pay for the transportation of portable x-ray equipment (R0070) provided on September 4, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for second- and third-degree burn excision or debridement.

You asked the Plan to pay for the anesthesia. 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 enrollee's terminal condition.

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. 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 anesthesia for second- and third-degree burn excision or debridement.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (74018) provided June 30, 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 this code shares a Column I/Column II relationship with another 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. In this case, we have confirmed that code 74018
has a Column I/Column II relationship with code 74240 and cannot be paid as billed. 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 an x-ray (74018) provided June 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing.

You asked the Plan to pay for MTHFR (5,10-methylenetetrahydrofolate reductase) (e.g., hereditary
hypercoagulability) gene analysis, common variants (e.g., 677T, 1298C) (81291). You say that the Plan should
pay this claim. The Plan denied your request. The Plan says this test is not covered by Medicare or the Plan.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

The test at issue in this appeal, MTHFR (5,10-methylenetetrahydrofolate reductase) (e.g., hereditary
hypercoagulability) gene analysis, common variants (e.g., 677T, 1298C) (81291), is not covered by Medicare.
Therefore, we decided that the Plan does not have to pay for the genetic testing.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services and an evaluation.

You asked the Plan to waive the copayment for outpatient rehabilitation services and an evaluation. You say that you thought that you would only owe one copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for outpatient rehabilitation services. A separate copayment applies to the initial evaluation and any re-evaluations.

You received outpatient rehabilitation services. Therefore, you are responsible to pay the $35 copayment.

You received an outpatient rehabilitation evaluation. Therefore, you are responsible to pay the $35 copayment.

The total amount you owe is: $70.

You have been asked to pay the total copayment amount of $70 for outpatient rehabilitation services and an evaluation. Outpatient rehabilitation services and an evaluation fall 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 outpatient rehabilitation services and an evaluation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for set up of portable x-ray equipment (Q0092) transportation of
portable x-ray equipment and personnel to home or nursing home (R0070) provided by an out-of-network (OON) provider.

You asked the Plan to pay for the portable x-ray services. You say that the medical records provided confirmed
that the services were provided as billed, so the charges in question are valid and payable, in which payment
needs to be made. The Plan denied your request. The Plan says the services was not authorized by the plan and
is therefore the services for beneficiaries is a non-covered stay.

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 Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

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 set up of portable x-ray equipment (Q0092)
transportation of portable x-ray equipment and personnel to home or nursing home (R0070) provided by an out-of-network (OON) provider.