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

We decided that the Plan does not have to pay for services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (99053) provided on October 28, 2020.

You asked the Plan to pay for the emergency department services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says your request is not a covered benefit.

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 the emergency department services has a status indicator of B and cannot be paid as billed. This means that payment for CPT code 99052 is subsumed by the payment for the services to which it is incident. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (99053) provided on October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a white glass crown (D2740) for tooth #2 and tooth #3 and custom abutments (D6057) for tooth #18 and tooth #19.

You asked the Plan to pre-approve the crowns and abutments. You say that these services are medically necessary. The Plan denied your request. The Plan says the glass crowns requested are not covered by the supplemental dental benefit, and custom abutments were already provided for tooth #18 and #19 in March 2021. These abutments were paid for. Up to two abutments may be covered in a calendar year. Any tooth may not receive more than one abutment within 5 calendar years.

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 crowns are not among those covered under this benefit and the abutments are requested in a frequency that exceeds what is allowed by this benefit. Documentation shows that this enrollee had the requested abutments previously performed in March 2021. The Plan has already paid for two abutments during this Plan year for the requested teeth. Therefore, we decided that the Plan does not have to pre-approve a white glass crown (D2740) for tooth #2 and tooth #3 and custom abutments (D6057) for tooth #18 and tooth #19.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor (CGM) provided on October 19, 2020.
You asked the Plan to pay for the supply allowance for a CGM. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the supplies are not documented in the enrollee's medical records.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The office notes are from May 18, 2020 and do not mention a CGM. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor (CGM) provided on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory work provided on January 15, 2021.

You asked the Plan to waive the deductible for the laboratory work. You say that the laboratory tests were done to assess your general health. You say your deductible was increased for laboratory work which had not been charged before. 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. Your contract with the Plan says that there is a $300 deductible that applies towards in-network Medicare-covered laboratory services. 

The laboratory work you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for in-network Medicare-covered laboratory services. This cost sharing is a contractual obligation that had not been met at the time the laboratory work was received on January 15, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory work provided on January 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 25, 2020.

You asked the Plan to pay for the ambulance services. 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 25, 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 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 14, 2020 by a non-participating provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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 office visit provided on September 14, 2020 by a non-participating provider.
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 IRF care is medically necessary for the enrollee. 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 in the Medicare rules section.

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 that the patient was admitted to an acute care hospital for aortic dissection. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Finally, there is not a reasonable expectation that this patient 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99213), and the test to determine if prescription eye wear is needed (92015) received December 22, 2020 from an out-of-network provider.

You asked the Plan to pay for the office visit and eye refraction. You say that the requested services were a follow up to a potentially serious medical concern. The Plan denied your request. The Plan says the provider in this case is out-of-network for vision care.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when performed by an in-network vision provider. 

We looked at the file and the Plan's rules. The provider in this case is not in-network for the Plan's vision care benefit . Based on this information, we decided that the Plan's rules for coverage of the office visit and eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the established patient office or other outpatient visit (99213), and the test to determine if prescription eye wear is needed (92015) received December 22, 2020 from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for presbyopia correcting function of intraocular lens (V2788 x2) provided from October 5, 2020, through October 27, 2020.

You asked the Plan to pay for presbyopia correcting function of intraocular lens. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says the service is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a conventional IOL.

While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for presbyopia correcting function of intraocular lens (V2788 x2) provided from October 5, 2020, through October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on November 3, 2020.

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 Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. 

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 supplies rendered on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster (shingles) vaccine provided on January 12, 2021.

You asked the Plan to pay for Zoster (shingles) vaccine (90750). You say that nobody at the clinic told you it was not covered. The Plan denied your request. The Plan says this vaccine is not covered under your Medicare Part B benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Zoster (shingles) vaccine (90750). The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to Zoster (shingles) vaccine (90750). Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine provided on January 12, 2021.

Benefits for Zoster (shingles) vaccine (90750) may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99308) provided on December 24, 2020.

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 pre-authorized. 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 had network providers available who could have provided the services 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 these services. Therefore, we decided that the Plan does not have to pay for nursing facility care (99308) provided on December 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for procedures on heart or insertion and placement of flow directed catheter provided on May 8, 2020.

You asked the Plan to pay for anesthesia for procedures on heart (00562) and insertion and placement of flow directed catheter (93503). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not include documentation of insertion and placement of flow directed catheter (93503) anesthesia (00562).

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 00562 is anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, age 1 year or older, for all noncoronary bypass procedures (eg, valve procedures) or for re-operation for coronary bypass more than 1 month after original operation. In this case, the CPT Code Manual definition of code 93503 is insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes. 

We find that CPT codes 00562 and 93503 are not supported in the medical record. Specifically, the records do not document these procedures were performed. Based on this information, we decided that Medicare rules for coverage of anesthesia for procedures on heart (00562) or insertion and placement of flow directed catheter (93503) have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for procedures on heart or insertion and placement of flow directed catheter provided on May 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on December 10, 2020 and December 14, 2020.

You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says authorization was not obtained.

The Plan contract says that outpatient rehabilitation services are covered and prior authorization is required after 12 visits.

We looked at the file and the Plan's rules. The file shows that authorization was not obtained. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on December 10, 2020 and December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953 x 2), the surgical extraction (D7210), and the prophylaxis (D1110) provided from December 21, 2020, to December 30, 2020.

You asked the Plan to pay for the dental services. You say that your previous claim for this provider was paid. You say that claim denied, you would have changed providers. You say that you are now in the middle of a procedure and cannot change providers. You also say that since the initial claim was paid, accidental or not, this one should be too. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services performed by a provider who has opted out of Medicare.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for the bone replacement graft (D7953 x 2), the surgical extraction (D7210), and the prophylaxis (D1110) provided from December 21, 2020, to December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210) provided on December 9, 2020.

You asked the Plan to pay for an intraoral complete series of radiographic images. You say that you were told by the provider that the services would be covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

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 an intraoral complete series of radiographic images (D0210) provided on December 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on December 3, 2020.

You asked the Plan to waive the copayment for the laboratory work. You say that you were told the copayment is not from laboratory work and it is something the insurance did not pay. 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 $10 copayment per day, per provider, for in-network Medicare-covered laboratory services. 

You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows the laboratory service was completed during the visit. 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 laboratory work provided on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the specialist visit provided on January 6, 2020.

You asked the Plan to waive the co-payment for the specialist visit. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received services provided by a specialist on the date of service at issue in this appeal. The Plan says that the correct co-payment has applied per your contract with the Plan.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 co-payment for services obtained from a specialist.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a specialist visit on January 6, 2020. You have been asked to pay a $50 co-payment for the specialist visit. The specialist visit falls within the Physician/Practitioner 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 co-payment for the specialist visit provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3330) and treatment of root canal obstruction (D3331) provided on February 18, 2021.

You asked the Plan to pay for the endodontic therapy and treatment of root canal obstruction. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services are not covered by the 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 endodontic therapy (D3330) and treatment of root canal obstruction (D3331) provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay in full for the periodic oral exam and prophylaxis provided on January 7, 2021 by an OON provider.

You asked the Plan to pay in full for the periodic oral exam and prophylaxis. You say that these services should be covered in full. The Plan denied your request. The Plan says the total $69.00 amount applied correctly as enrollee liability. The Plan also says that cost sharing is a contractual obligation under the Plan 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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay in full for the periodic oral exam and prophylaxis provided on January 7, 2021 by an OON provider.