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

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on
August 2, 2019.

You asked the Plan to pay for the evaluation and management service. You say that the provider rendered
medically necessary services to the enrollee in good faith. The Plan denied your request. The Plan says the
enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it
is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on August 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two preventive procedures and two extractions provided
on December 11, 2020, and January 20, 2021, by a Medicare opt-out provider.
You asked the Plan to pay for the preventive procedures and extractions. You say that the enrollee was not
aware that this treating provider does not accept Medicare. The Plan denied your request. The Plan says these
services were rendered by a privately contracted 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the
Plan does not have to pay for the two preventive procedures and two extractions provided on December 11,
2020, and January 20, 2021, by a Medicare opt-out provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breathing capacity test (94010) provided on November 10, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $20 copayment for Medicare-covered outpatient diagnostic tests rendered by an in-network provider.
You have been asked to pay a $20 copayment for the Medicare-covered outpatient diagnostic test rendered by an in-network provider. 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 breathing capacity test (94010) provided on November 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for reconstructive procedures of the eyelid (00103) rendered by the out of network (OON) provider on November 4, 2019.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the anesthesia for reconstructive procedures of the eyelid (00103) rendered by the out of network (OON) provider on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on June 29, 2020.
You asked the Plan to pay for the office visit. You say that you were unable to get authorization before the service was done due to the short time period. You say that the medical records show the necessity of the service and the claim should be considered for payment. The Plan denied your request. The Plan says prior authorization was required but not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
The requested provider in this case is not a network provider with the Plan. The Plan 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 by an out-of-network provider on June 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.

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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the office/outpatient visit (99213) and the after-cataract laser surgery (66821) provided on December 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient visit and after cataract laser surgery. You say that you were told by the provider's office that the provider was in-network. The Plan denied your request. The Plan says you must receive your care from a network provider.
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/outpatient visit (99213) and the after-cataract laser surgery (66821) provided on December 21, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transport (A0428) provided on August 31, 2020.

You asked the Plan to pay for the ground mileage and ambulance transport. You say that the enrollee is an ongoing dialysis patient, and requires several transports to and from treatments. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility is not a Medicare covered benefit.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

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 ground mileage and ambulance transport. Our reviewer says that the non-emergency ambulance transport did not meet coverage criteria. Our physician reviewer found the documentation supports that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were not contraindicated for this enrollee on August 31, 2020. Our reviewer found that the documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. Our physician reviewer also found that the documentation did not support that the ambulance transport on August 31, 2020 was medically reasonable and necessary for the enrollee.

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 ground mileage and ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transport (A0428) provided on August 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing services provided on September 18, 2020.
You asked the Plan to pay for the services provided. You say that the services are beneficial in predicting response to treatment and improving clinical outcomes. The Plan denied your request. The Plan says the services are considered experimental.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the provider must corroborate the documentation in the beneficiary's medical documentation.
The file shows that the enrollee received a targeted genomic sequence analysis panel. We looked at the file and Medicare rules. The medical records do not show that the test results would improve the enrollee's outcome or change the physicians care and/or treatment of the enrollee.
Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits (99214), injections (20553), and osteopathic manipulation (98928) provided from September 8, 2020, to January 19, 2021, by an out of network (OON) provider.

You asked the Plan to pay for OON office visits, injections, and osteopathic manipulation. You say that you believed these services were approved. The Plan denied your request. The Plan says these services were not authorized.

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 office visits (99214), injections (20553), and osteopathic manipulation (98928) provided from September 8, 2020, to January 19, 2021, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the office visit and laboratory services provided on January 11, 2021.
You asked the Plan to waive the cost for the office visit and laboratory services. You say that you joined the Plan because you were told it was cheaper. You say that this is twice what you were paying and want to know if the charges are out-of-network. The Plan denied your request. The Plan says the cost share 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 there is a combined deductible amount of $203 for covered Part B services from both in-network and out-of-network providers. Until you have paid the combined deductible amount, you must pay the full cost for covered Part B services from in-network or out-of-network providers. Your contract with the Plan also says that you must pay a $20 copayment for provider and professional services at an in-network primary care physician's office. The item or service you asked the Plan to waive the cost for falls within the "Physician/Practitioner services, including doctor's office visits" and "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $203 deductible applies to office visits and diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time the office visit and laboratory services were received on January 11, 2021. Therefore, $203 has been applied to meet your deductible.
Since your $203 deductible was met, you have also been asked to pay $17.98, which is less than the standard $20 copayment for the office visit. The records show you were charged the in-network rate. 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 cost for the office visit and laboratory services provided on January 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care for the elective left shoulder arthroplasty and biceps tenodesis (Current Procedural Terminology (CPT) code(s): 23472-LT and 23430-LT).
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The Pan states the procedures are not listed on the CMS Inpatient Only List.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is scheduled to have a left shoulder arthroplasty. The medical records provided do not indicate the treating physician's reasonable expectation of a length of stay spanning two (2) or more midnights. The initial day should be spent in observation until it is clearly expected that a second midnight would be required, at which time the physician may order inpatient admission. The elements of the coverage rule are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care for the elective left shoulder arthroplasty and biceps tenodesis (Current Procedural Terminology (CPT) code(s): 23472-LT and 23430-LT).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for a specialist visit provided on January 29, 2021.

You asked the Plan to waive the co-payment for a specialist visit. You say that this was a follow-up visit and you should not be responsible for the 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 co-payment for specialist services.

You had a specialist visit on January 29, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $30 co-payment.

You have been asked to pay a $30 co-payment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the canal preparation and fitting of preformed dowel or post (D3950) provided on February 2, 2021.

You asked the Plan to pay for the canal preparation. The Plan denied your request. The Plan says this procedure is not covered.

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 canal preparation and fitting of preformed dowel or post (D3950) provided on February 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. 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 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 reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the health plan's denial of LTACH coverage should be upheld. The patient is
currently undergoing treatment at an ACH for a sacral pressure wound and renal failure. 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. The enrollee can remain at the current ACH until such time no acute services are
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.

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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thirty-six (36) additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that you need urgent transportation for the doctors because you have chemotherapy treatment. The Plan denied your request. The Plan says this request exceeds your benefit.

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.

We looked at your request, the records in the case file, and the rules. Based on this information, this request exceeds your benefit allowance. Your 2021 EOC states up to 35 one-way trips are covered per calendar year.
Therefore, we decided that the Plan does not have to pre-approve thirty-six (36) additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954)
provided on March 24, 2021.

You asked the Plan to pay for the prefabricated post and core. You say that you feel this service should be
covered because you have dental coverage. The Plan denied your request. The Plan says this procedure is not
covered. The Plan also says that your plan does not include benefits under Class 3 Major Services.

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
prefabricated post and core in addition to crown (D2954) provided on March 24, 2021.