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

We decided that the Plan does not have to pay for the services
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 claim was not billed correctly 
The Plan must follow Medicare rules. The rules say that CMS does not pay for an "inpatient-only" service
furnished to a person who is registered in the hospital as an outpatient and reports the service on the outpatient
hospital bill type (TOB 13X).
We looked at the file and Medicare rules. The file shows that the provider billed inpatient services with an
outpatient TOB code of 131. 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 services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 based on the documentation provided, it is my opinion that the health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR, outpatient rehabilitation). 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care (99308) rendered by the out of network (OON) provider on December 17, 2019.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the services were 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 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 forthe subsequent nursing facility care (99308) rendered by the out of network (OON) provider on December 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on November 9, 2019.You asked the Plan to waive the copayment for the CT scan. You say that this CT scan was ordered as a preventive measure. You say your only income is Social Security. The Plan denied your request. The Plan says you have been charged 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 $180 copayment for advanced imaging services at an in-network freestanding radiological facility. You have been asked to pay a $180 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows the reason for the CT scan was due to a pulmonary nodule and hematuria which makes the CT scan diagnostic in nature.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 CT scan provided on November 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 11, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say thatplans 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 forthe medical services provided to the enrollee by an out-of-network provider on September 11, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued posterior tibial instrumentation for the enrollee.
You asked the Plan to pre-approve the continued treatment. You say that these treatments have been beneficial. The Plan denied your request. The Plan says this request is not medically necessary because the records show completion of a lifetime total of 45 visits for this treatment.
The Plan must follow Medicare rules. Medicare rules say that posterior tibial instrumentation is limited to three years of treatment and 45 individual visits. The file shows that the enrollee has received 45 treatments for this case. The appeal letter also shows that treatment has been going on longer than three years. Based on this information, we decided that Medicare rules for coverage of the continued treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve continued posterior tibial instrumentation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.You asked the Plan to pre-approve the allowance for healthy food purchases and/or electricity, water and/or phone bill payments.The Plan denied your request. The Plan says you do not have an eligible chronic medical condition for the allowance.The Plan contract says that, in order to be eligible for an allowance, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning.In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and Medicare rules. The file shows that your medical conditions are not eligible medical conditions under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay formedical nutrition therapy services provided to the enrollee on December 16, 2019.You asked the Planto pay formedical nutrition therapy services. You say that the medical records show the medical necessity of the denied services.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes.Therefore, we decided that the Plandoes not haveto pay formedical nutrition therapy services provided to the enrollee on December 16, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services rendered to enrollee from October 11, 2018 to November 19, 2018.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that the beneficiary can be covered for an unlimited number of nonoverlapping episodes. The duration of a single full-length episode is 60 days.We looked at the file and Medicare rules. The file shows that the claims were submitted more than 120 days after the date of service. 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 home health services rendered to enrollee from October 11, 2018 to November 19, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309) provided on October 31, 2019. You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available. 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 nursing facility care (99309) provided on October 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says you are covered for up to 12 one-way trips
per calendar year. The Plan says that you have used all 12 one-way trips allotted for the 2020 benefit year and
no additional trips can be approved.
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 12 one-way transportation 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 routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crown porcelain/ceramic teeth 13,15 (D6740) pontic porcelain/ceramic tooth 14 (D6245) and local anesthesia in conjunction with operative or surgical procedures, tooth 14 (D9215).
You asked the Plan to pre-approve the dental services. You say that you had services for an x-ray being denied and you had a bridge put in but it is deteriorating and you need a new one. The Plan denied your request. The Plan says the requested procedures are not listed as covered under the plan benefits.
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 health plan contract says that only the services listed is covered. 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 retainer crown porcelain/ceramic teeth 13,15 (D6740) pontic porcelain/ceramic tooth 14 (D6245) and local anesthesia in conjunction with operative or surgical procedures, tooth 14 (D9215).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the train-of-four (TOF) testing provided during intraoperative neuromonitoring (IONM) on June 13, 2019 billed with CPT code 95999.


You asked the Plan to pay for the TOF testing. You say that this cannot be denied as not medically necessary since the treating physician deemed it to be necessary. The Plan denied your request. The Plan says all services were paid aside from the code 95999 which was denied as included in payment for the other billed services.

The Plan must follow Medicare rules. Medicare rules say that all services which are integral to accomplishing a procedure are considered a component part of a comprehensive code.

IONM services cannot be performed without TOF monitoring. This means that TOF testing is considered integral to the performance of IONM services. As such, this component of the procedure is included in payment for the overall IONM monitoring service which was already paid. No separate payment can be made for this part of the service. Therefore, we decided that the Plan does not have to pay for the train-of-four (TOF) testing provided during intraoperative neuromonitoring (IONM) on June 13, 2019 billed with CPT code 95999.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you are ill due to your urinary
incontinence and you need the requested diapers. You say that the quantity you have been provided are not
enough. You received sixty diapers and you say that you really need one hundred and eighty due to the fact that
you use two a day. You say that you do not agree with the Plan's denial. The Plan denied your request. The
Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1832).You asked the Plan to pre-approve the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the orthosis. Our reviewer says that the documentation does not support medical necessity. Our physician reviewer found the submitted documentation does not support a physical examination of knee instability. Without the supporting documentation, medical necessity is not determined. Medicare guidelines 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 the orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1832).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on November 20, 2019.You asked the Plan to waive the copayment for the laboratory work. You say that the lab work was ordered during your routine physical and you feel that the laboratory work should be covered in full. The Plan denied your request. The Plan says you have been charged 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 $15 copayment for each Medicare-covered lab test.You have been asked to pay a $15 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the laboratory work is considered a separate service.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractualobligation 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 laboratory work provided on November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on October 17, 2019.You asked the Plan to waive the deductible for the office visit. You say that the Plan had no right to change the cost.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $750, which applies to all items and services except those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Out-of-network physician services are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to out-of-network office visits This cost sharing is a contractual obligation that had not been met at the time the office visit was received on October 17, 2019.Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on October 17, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care (99309) rendered by the out of network (OON) provider on September 15, 2019.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the services were provided 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 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 forthe subsequent nursing facility care (99309) rendered by the out of network (OON) provider on September 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the first-responder services you received on September 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a Medicare-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 September 7, 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 first-responder services you received on September 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for debridement procedure on the skin provided by an in-network provider on February 21, 2019.You asked the Plan to waive the copayment for an outpatient surgery. You say that you say the doctor for 3-4 minutes. You say that you do not think the services that were provided do not warrant these charges.The Plan denied your request. The Plan says the correct copayment 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 $275 copayment for outpatient surgery. You have been asked to pay a $275 copayment for an outpatient surgery. The services that were provided to you are considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls 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 copayment for debridement procedure on the skin provided by an in-network provider on February 21, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe skilled nursing facility (SNF) services provided from September 5, 2019 to September 29, 2019.You asked the Plan to waive the copayment forthe SNF services. The Plan denied your request. The Plan says that the claim processed 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 days 1-20 of SNF care and a $60 copayment fordays 21-100 of SNF care. You have been asked to pay a $300copayment for the SNF services. The SNF services falls within the days 1-20 of SNF care benefit categoryand days 21-100 of SNF care 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 forthe skilled nursing facility (SNF) services provided from September 5, 2019 to September 29, 2019.