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

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and an unspecified preventive procedure (D1999) provided on October 14, 2020.
You asked the Plan to pay for a periodic oral evaluation, a teeth cleaning, and an unspecified preventive procedure. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, a teeth cleaning, and an unspecified preventive procedure have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan
has contracted providers available to provide these services. 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 a periodic oral evaluation (D0120), a teeth cleaning (D1110), and an unspecified preventive procedure (D1999) provided on October 14, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the copayment for inpatient hospital services provided by a participating hospital on November 19, 2020, to December 10, 2020.
You asked the Plan to waive the copayment for inpatient hospital services. You say that you do not agree with these charges. The Plan denied your request. The Plan says that the correct charges have been applied.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has failed to send in enough information and evidence to show that the correct cost sharing amounts were applied. Therefore, we decided that the Plan has to waive the copayment for inpatient hospital services provided by a participating hospital on November 19, 2020, to December 10, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumococcal vaccine (90732) and administration (G0009)
provided on December 21, 2020.
You asked the Plan to pay for a pneumococcal vaccine and administration. You say that the enrollee came to
the office to receive these services. The Plan denied your request. The Plan says these services were billed as
telehealth services.
The Plan must follow Medicare rules. Medicare rules say that Place of Service (POS) code 02 is used to
indicate telehealth.
We looked at the file and Medicare rules. The services at issue were billed with POS 02 for telehealth, but
these services cannot be provided through telehealth. Based on this information, we decided that Medicare
rules for coverage of a pneumococcal vaccine and administration have not been met. Therefore, we decided
that the Plan does not have to pay for a pneumococcal vaccine (90732) and administration (G0009) provided on December 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0220), and re-cement or re-bond of a crown (D2920) provided on January 15, 2021.
You asked the Plan to pay for an intraoral periapical radiographic image, and re-cement or re-bond of a crown. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network provider.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an intraoral periapical radiographic image, and re-cement or re-bond of a crown have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 an intraoral periapical radiographic image (D0220), and re-cement or re-bond of a crown (D2920) provided on January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the sacroiliac joint injection provided on April 8, 2020 by an out-of-network provider.
You asked the Plan to make additional payment for the injection. You say that you paid up front for this service and have always been reimbursed completely in the past. You feel that more payment should be made. The Plan denied your request. The Plan says this claim was paid at the full Medicare-allowed rate.
The Plan must follow Medicare rules. The rules say that Plans must pay non-contracted providers up to the Medicare-allowed amount for services rendered. In this case, the procedure code for the services you received is 27096. The identification code from the provider is for an ambulatory surgical center, which is considered a facility setting. The Medicare-allowed amount for this code in an out-of-network facility is $80.70 in your locality. This is the amount that your Plan reimbursed you, so the Plan has paid for these services appropriately. This provider has charged an amount above the Medicare-allowed amount. You have the right to go back to the provider and request a refund, advising them that you have a Medicare Advantage Plan. However, the Plan itself is not obligated to make any
further payment. Therefore, we decided that the Plan does not have to make additional payment for the
sacroiliac joint injection provided on April 8, 2020 by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation (A0428, A0426), and ground mileage (A0425 x2) provided from February 16, 2021, through February 17, 2021.
You asked the Plan to waive the copayment for non-emergency ambulance transportation, and ground mileage. You say that the hospital told you that you had to take an ambulance. You cannot afford to pay for the services. The Plan denied your request. The Plan says the co-payment 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 $200 copayment for ambulance services. You have been asked to pay a $200 copayment for non-emergency ambulance transportation, and ground
mileage. The services at issue 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 non-emergency ambulance transportation (A0428, A0426), and ground mileage (A0425 x2) provided from February 16, 2021, through February 17, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on February 28, 2021.
You asked the Plan to waive the copayment for an emergency room visit. You say that the nurse administrating your vaccine pricked herself with the needle. You say that you were told to go to the ER because that was protocol. You say that you should not have to pay for this. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. Since an emergency room visit was
provided, the correct copayment has been applied. An emergency room visit 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 an emergency room visit provided by a participating provider on February 28, 2021.
We note your complaint about having to go to the emergency room due to the nurse's mistake. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on June 17, 2020.

You asked the Plan to pay for the diagnostic radiology services.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 member's terminal condition. The Medicare hospice benefit,through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the 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 diagnostic radiology services provided on June 17, 2020.
Appeal type: Imaging
Decision: Favorable

You asked the Plan to pay for the CT scan. You say that you should have called for in-network providers in the area. You say that you were not advised they were out-of-network and you are not responsible for payment. The Plan denied your request. The Plan says that there was no authorization on file for the out-of-network provider and in-network providers were available.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. 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 the CT scan. Our reviewer says that the CT scan was necessary to assess the serious rib and chest wall injury. Our physician reviewer found that you were unable to travel back to your home for in network services due to the age and discomfort of the traumatic injury. Our reviewer says that since you were unable to travel safely due to your age and injuries, the out of network scan was 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 CT scan have been met. Therefore, we decided that the Plan has to pay for the CT scan provided by an out-of-network provider on October 29, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for crowns (D2752) provided from March 16, 2021, through March 30, 2021.
You asked the Plan to pay an additional amount for crowns. You say that you want to utilize leftover dental allowance from 2020 to pay for these services. The Plan denied your request. The Plan says the claims must be processed with the benefits for the calendar year in which the services were rendered.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of crowns have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Any amount beyond the allowed amount is your contractual responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for crowns (D2752) provided from March 16, 2021, through March 30, 2021.
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 the services are necessary. 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 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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services or to require regular physician evaluation. The enrollee's care needs can be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on November 22, 2020.
You asked the Plan to pay for the subsequent hospital care (99233). You say that claims have been billed before with the same diagnosis codes and they were process and paid. The Plan denied your request. The Plan says the diagnosis codes identify two conditions that cannot be reported together except when the two conditions are unrelated.
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 diagnosis code J96 cannot be claimed with diagnosis code J80. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care (99233) have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided on November 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a grab bar provided on March 5, 2019.
You asked the Plan to pay for a grab bar. You say that this is medically necessary. 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 grab bars are not covered because they are not primarily medical in nature. While a grab bar 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 pay for a grab bar provided on March 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vein mapping to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve vein mapping to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 vein mapping to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a couple's gym membership fee provided on January 15, 2020.
You asked the Plan to reimburse you for the couple's gym membership fee. You say that you want the original amount due. The Plan denied your request. The Plan says the reimbursement benefit was applied correctly. The Plan can only reimburse you for your individual membership costs.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because the Plan can only reimburse you for your individual membership costs. Therefore, we decided that the Plan does not have to reimburse you for a couple's gym membership fee provided on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient surgery, emergency room services, and inpatient hospital care provided August 3, 2020, to October 19, 2020.
You asked the Plan to waive the cost share for the outpatient surgery, emergency room services, and inpatient hospital care. You say that you would like these claims reprocessed and the cost shares waived. The Plan denied your request. The Plan says the cost shares have processed correctly at this time.
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 $250 copayment for outpatient surgery, a $65 copayment for each emergency room visit, and a $160 copayment each day for days 1 to 10 for Medicare-covered hospital care. The enrollee has been asked to pay a total cost share of $2819.95 for the outpatient surgery, emergency room services, and inpatient hospital care. These services fall within the outpatient surgery, emergency room visit and Medicare-covered hospital care benefit categories. In addition, the enrollee also reached their Plan out-of-pocket maximum which means the remaining services after this were fully covered. 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 cost share for the outpatient surgery, emergency room services, and inpatient hospital care provided August 3, 2020, to October 19, 2020.
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 the additional transportation is needed. The Plan denied your request. The Plan says the benefit has been exhausted.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor.
You asked the Plan to pre-approve a Freestyle Libre 2 sensor. You say that the item is not medically necessary. 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. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor.