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

We decided that the Plan does not have to waive the copayment for the nail debridement (11721) provided on
September 28, 2020.
You asked the Plan to waive the copayment for the nail debridement. You say that you have had this service or
visit several times and have never been charged a copay. The Plan denied your request. The Plan says nail
debridement is classified as a surgical service or procedure. Outpatient surgery is subject to a $275 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 $275
copayment for outpatient surgery and services.
You have been asked to pay a $49.56 copayment for the nail debridement. The Plan's allowed for this service
is $49.56, so you have been asked to pay less than the maximum copayment for the surgical procedure. Nail
debridement falls within the outpatient surgery and 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 nail debridement (11721) provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the subsequent nursing facility care (99308) provided on November 11, 2019.. You say that you would like reconsideration because this provider rendered medically necessary services in good faith. The Plan denied your request. The Plan says services from non-participating providers are not covered unless they are authorized by the Plan prior to the services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound examination provided on October 20, 2020.
You asked the Plan to waive the copayment for ultrasound. You say that you feel this copayment should be waived because it was a minor scan. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $100 copayment for ultrasound. You have been asked to pay $100 copayment for ultrasound. Ultrasound falls 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 copayment for an ultrasound examination provided on October 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Comprehensive metabolic panel (80053) provided November 16, 2020.

You asked the Plan to waive the copayment for the Comprehensive metabolic panel. You say that you believe the service should be included as part of your wellness visit. The Plan denied your request. The Plan says the copayment was 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 $10 copayment for Medicare-covered laboratory tests 

You have been asked to pay a $10 copayment for the Comprehensive metabolic panel. This service falls 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 copayment for the Comprehensive metabolic panel (80053) provided November 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services.

You asked the Plan to pay for the paramedic intercept services. You say that you were being transported and were told you had water in your lungs. The Plan denied your request. The Plan says this service is not a covered benefit.

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 as defined above. It is noted that the only State in which these criteria are met is New York. 

The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 10 extractions (D7140) and the immediate upper denture (D5130) provided on August 18, 2020.
You asked the Plan to pay for the dental services. You say that the services should be reviewed as medically necessary. You say that your cardiologist refused to submit a prior authorization. You say that the extractions were medically necessary due to cardiac problems. You also say that you do not believe that this is a dental reimbursement claim. The Plan denied your request. The Plan says the services that were provided are dental in nature. The Plan also says that the annual maximum allowance of $415 has been exhausted.
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 annual maximum allowance of $415 has been exhausted. The record shows that the Plan paid 4 of the extractions that you received on this date of service. The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the 10 extractions (D7140) and the immediate upper denture (D5130) provided on August 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane injections (J7318).

You asked the Plan to pre-approve Durolane. You say that Durolane is medically necessary. The Plan denied
your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

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 Durolane. Our reviewer says that
Durolane is not medically necessary. Our physician reviewer found the record does not show a trial of the plan
preferred drugs or any reason why the plan preferred drugs would be unsafe or ineffective.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have
to pre-approve Durolane injections (J7318).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on August 11, 2020.

You asked the Plan to pay for drug tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS) code. 

We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken in an office setting, therefore the Place of Service (POS) code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, pulpal debridement, or pay more for the extraction provided on November 24, 2020, and November 30, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation, pulpal debridement, and pay more for the extraction. You say that you were under the impression that these services would be covered by your insurance. The Plan denied your request. The Plan says the problem focused limited oral evaluation and pulpal debridement are not covered benefits. The Plan also says that you are responsible for a 50% coinsurance for the extraction.

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, problem focused limited oral evaluation and pulpal debridement are not among those covered under this benefit. The contract also clearly states that you are responsible for a 50% coinsurance for the extraction. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, pulpal debridement, and pay more for the extraction provided on November 24, 2020, and November 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for wheelchair van transportation (A0130).

You asked the Plan to pay for wheelchair van transportation. You say that this was the only way for you to get to your appointment. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services.

The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for wheelchair van transportation (A0130).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for debridement provided on August 13, 2020.

You asked the Plan to waive the copayment for debridement. You say that you disagree with the high charges for the service you received. 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 $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. 

You have been asked to pay the allowed amount of $261.85, which is less than the $295 copayment for debridement. Debridement falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 debridement provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection.

You asked the Plan to waive the coinsurance for the denosumab injection. You say that you had this injection before with no coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 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% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay 20% coinsurance for the denosumab injection. The denosumab 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 the denosumab injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for eye exam. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on August 5, 2020.

You asked the Plan to waive the copayment for ambulance trips. You say that you are requesting that the Plan help you with this bill. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $350 copayment per trip for ambulance services. There were 2 trips, resulting in a total copayment obligation of $700. 

You have been asked to pay $350 copayment per trip for ambulance services. Ambulance trips fall within the Ambulance 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 ambulance transportation provided on August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for anesthesia service. You say that no authorization or referral is required for this service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the service was not referred by an in-network provider or facility.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90834) provided October 15, 2020.

You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says this provider is not eligible for payment.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90834) provided October 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee.

You asked the Plan to pay for this transport. You say that because the rules for non-emergent destinations were expanded due to Covid-19, this transport should be covered. The Plan denied your request. The Plan says Medicare coverage criteria for transport were not met.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. While it is agreed the destinations for transport were broadened due to Covid-19, the enrollee is still required to meet the criteria for non-emergent transport. 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 this transport. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the records show the enrollee was a 66-year-old obese man on home oxygen at the home facility transported by ambulance for a routine cardiology appointment. The documentation indicates the enrollee was supine, alert and oriented. There was no physician certification of medical necessity for transport by ambulance. Medicare statutes provide that ambulance services are only covered when the enrollee's clinical condition is such that other methods of transport are contraindicated. In this case, the record does not indicate that the enrollee required ambulance transport. Medicare coverage criteria are not 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 this transport have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request.
The Plan says rules for IRF care have not been met.

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 complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, you do not
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. The medical record documents a need for physical and occupational
therapy but not for an intensive rehabilitation program. Medial necessary services could be provided in a low
level of care. Finally, there is a not reasonable expectation that you will be able to fully participate in and
benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.