Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe two amalgams provided on December 4, 2019.You asked the Plan to pay forthe amalgams. You say that you received bad dental work with two fillings on the lower right side of your mouth.The Plan denied your request. The Plan says this claim was processed correctly according to your 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.Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a 50% coinsurance for amalgam restorations on posterior  teeth when they are received by an in-network provider. The record shows that you were charged correctly at 50% for each amalgam.Therefore, we decided that the Plan does not have to pay forthe two amalgams provided on December 4, 2019.Your complaint about being dissatisfied with the bad dental work this provider rendered is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory test provided on December 30, 2019.
You asked the Plan to waive the copayment for the laboratory test. You say that the laboratory services were preventive because the member is diabetic. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $10 copayment for Medicare-covered laboratory tests. This copayment does not apply to blood draws or INR testing (anti-coagulant testing). You will only pay one copayment per day even if multiple labs are performed. The enrollee has been asked to pay a $10 copayment for the laboratory test. The laboratory test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the laboratory service is not considered a preventive service.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory test provided on December 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Ambulance Transport (A0428, A0425) provided October 22, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 Ambulance Services. You have been asked to pay the Medicare allowed amount, a $262.94 copayment for the ambulance transport. This is less than the $275 stipulated in the plan contract. The ambulance transport falls 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 an Ambulance Transport (A0428, A0425) provided October 22, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammogram provided on August 14, 2019.
You asked the Plan to pay for the radiology service. You say that the claim denied as a duplicate in error. You also say that the services were rendered by the provider The Plan denied your request. The Plan says during the enrollee's hospice election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the mammogram provided on August 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Budesonide-Formoterol 160-4.5 for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Budesonide-Formoterol
160-4.5 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on November 12,
2019.
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the additional
charges. 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 $100
copayment for diagnostic radiology.
You have been asked to pay the allowed amount of $70.18, which is less than the $100 copayment for an
ultrasound. An 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 provided on
November 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extractions and surgery to be provided by a non-participating dental provider.You asked the Plan to pre-approve the extractions and surgery. You say that this provider you are requesting can and will be able to remove all the teeth at once. You also say that you have dealt with these dentists for years.The Plan denied your request. The Plan says this provider is an Opt-Out provider and is therefore ineligible to participate in Medicare or accept Medicare payments. The Plan also says that because this provider has opted out of Medicare, the services are not covered by Medicare or the Plan.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 requested services at issue in this appeal are to be provided in a non-urgent, non-emergent situation by a non-participating dental provider. This provider has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pre-approve the extractions and surgery to be provided by a non-participating dental provider.Your complaint about being dissatisfied with the provider the Plan sent you to for dental work is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tub stool/bench.You asked the Plan to pre-approve a tub stool/bench. You say that you need this item for the benefit of your health.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that bath chairs are not covered because they are not primarily medical in nature. While a bath chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a tub stool/bench.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued group therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that switching providers at this time may cause undue stress and place her sobriety at risk. The Plan denied your request. The Plan says this provider is not contracted with Medicare.
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. You are not a contracted provider with Medicare. Therefore, we decided that the Plan does not have to pre-approve continued group therapy for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs daily physician visits, daily labs, wound care, therapy, and pulmonary management. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the present acute care facility, and still requires acute level of care services.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) following surgery to remove a lumbar mass. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Emergency Room services provided
January 4, 2020.
You asked the Plan to waive the copayment for the Emergency Room services. You say that the copayment
should be waived. The Plan denied your request. The Plan says the correct cost-sharing was 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 $50
copayment for Emergency Care.
You have been asked to pay a $50 copayment for the Emergency Room services. The Emergency Room
services falls within the Emergency 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
for the Emergency Room services provided January 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the destruction of a peripheral nerve or branch (64640).
You asked the Plan to pre-approve the destruction of a peripheral nerve or branch. You say that you are trying to avoid surgery. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the destruction of a peripheral nerve or branch. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is experimental/ investigational because of the wide variation in efficacy in the peer reviewed literature. Therefore, the request is deemed not medically reasonable or necessary. 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 destruction of a peripheral nerve or branch have not been met. Therefore, we decided that the Plan does not have to pre-approve the destruction of a peripheral nerve or branch (64640).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Diagnostic Mammogram (77066)
provided October 17, 2019.
You asked the Plan to waive the copayment for the mammogram. You say that the copayment should be
waived. The Plan denied your request. The Plan says the correct copayment was 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 $100
copayment for Diagnostic Radiology.
You have been asked to pay a $100 copayment for the mammogram. The mammogram falls within the
Diagnostic Radiology 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 a Diagnostic
Mammogram (77066) provided October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 20, 2019 by a
non-network 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-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 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 medical services provided on November 20,
2019 by a non-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge services provided on December 26, 2019You asked the Plan to pay for the observation care discharge services. You say that the end date for hospice was December 23, 2019, which was prior to this date of service.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 on December 23, 2019. 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 observation care discharge services provided on December 26, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on August 14, 2019.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed.
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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the record does not indicate that more than 30 minutes of hospital discharge day management services were rendered. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on August 14, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member is status-post acute care admission. The member continues to receive wound care. The member requires oversight of her medical conditions and medication management. She has cognitive impairment and would not be expected to be able to adjust medications or self-monitor her medical conditions. She is at risk for secondary complications related to her fall such as pressure ulcers. The member has not returned to her prior level of function. The member requires physical therapy for mobility and assessing the need for an assistive device. An occupational evaluation is indicated to assess the need for any adaptive equipment. There are skilled needs, but they do not need to be provided on a daily basis. The member is ambulating and performing essential activities of daily living without hands on assistance. The member's condition would not be expected to deteriorate with services provided on a less than daily basis. Her care can be continued at an alternate level. Consideration could be given to a home evaluation to see whether she is able to function better in her own, familiar environment. If she
has home health services available and, if she is able to function better at home, home-based care with services would be the best option for her. Alternatively, her care can be provided at a custodial level with intermittent skilled services at an assisted living facility as suggested when seen for physical therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that the services are necessary for you to be able to safely return home.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy services on a daily basis. You do 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Transthoracic Echocardiography (93306) provided on October 17, 2019.
You asked the Plan to pay for the echocardiography. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available. The service was not preauthorized or emergent.
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 Transthoracic Echocardiography (93306) provided on October 17, 2019.