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

We decided that the Plan does not have to pay for continuation of SNF services provided from
February 20, 2021, through February 23, 2021.

You asked the Plan to pay for continuation of SNF services. You say that continuation of SNF services was
medically necessary. The Plan denied your request. The Plan says continuation of SNF services was not
medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 pay for continuation of SNF services. Our reviewer
says that daily skilled services are not medically necessary. Our physician reviewer found that based on review
of the available records, the enrollee did not meet the CMS coverage criteria for continuation of care at an SNF
beyond February 19, 2021. The enrollee's main diagnosis is debility, and the enrollee was medically stable.
There are no documented rehabilitation nursing needs. At the current level of function (therapists discharged
her at high function), she did not require daily skilled therapy services on an inpatient basis in a SNF on the
dates in question. Continuation of stay at a SNF was not medically necessary beyond February 19, 2021.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the
Plan does not have to pay for continuation of skilled nursing facility (SNF) services provided from
February 20, 2021, through February 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on March 31, 2021.

You asked the Plan to waive the copayment for an MRI. You say that you were told that you would not owe a copayment and disagree with 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for diagnostic radiology services. 

You have been asked to pay a $150 copayment for an MRI. An MRI 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 MRI provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and urinalysis provided on January 8, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit and urinalysis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 and urinalysis provided on January 8, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays provided on April 6, 2021.

You asked the Plan to pay for the intraoral x-rays. You say that the office told you they accepted your insurance and you did not know they were out-of-network. You say that you cannot pay for the services that were denied. The Plan denied your request. The Plan says the claim reprocessed to allow payment for the periodic oral evaluation and bitewing x-rays. The Plan also says that intraoral x-rays are remain denied.

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, intraoral x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-rays provided on April 6, 2021.
Appeal type: ER
Decision: Unfavorable

2021.
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the denied 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency care. Emergency care 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 emergency care provided on March 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient therapy provided from January 8, 2021, through February 8, 2021.

You asked the Plan to waive the deductible for outpatient therapy. You say that you only went through physical therapy because you thought it would be covered by the Plan at no cost to you. You say that the burden should not be on you to be responsible for this bill. The Plan denied your request. The Plan says the deductible applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services."

The item or service you asked the Plan to waive the deductible for falls within the "Outpatient rehabilitation services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to outpatient rehabilitation services." This cost sharing is a contractual obligation that had not been met at the time outpatient therapy was received from January 8, 2021 to February 8, 2021. Therefore, we decided that the Plan does not have to waive the deductible for outpatient therapy provided from January 8, 2021, through February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the charges for adjust the charges for the eyewear purchased on March 31, 2021.
You asked the Plan to adjust the charges for the eyewear. You say that the charges are too high, and you have paid too much. The Plan denied your request. The Plan says the provider is refunding your $50 copayment and clip-ons are not covered.
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 up to $200 towards eyewear every year. We looked at the file and the Plan's rules. The Plan has applied the $200 towards the eyeglasses. Based on this information, we decided that the Plan's rules for coverage of the eyewear allowance have been met. Therefore, we decided that the Plan does not have to adjust the charges for adjust the charges for the eyewear purchased on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330), first intraoral periapical x-ray (D0220), and two additional intraoral periapical x-rays (D0230 x2) provided on April 14, 2021.
You asked the Plan to pay for the panoramic x-ray and intraoral periapical x-rays. You say that you thought these services would be provided with a $0 copay. You also say that you are requesting these x-rays to be covered because it will be a financial hardship. The Plan denied your request. The Plan says these services are 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 panoramic x-ray (D0330), first intraoral periapical x-ray (D0220), and two additional intraoral periapical x-rays (D0230 x2) provided on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on February 18, 2021 by an out-of-network
(OON) provider.

You asked the Plan to pay for drug testing. You say that this testing was medically necessary and should be
covered as in-network. The Plan denied your request. The Plan says the denial of payment for this testing is
correct, because this provider is out-of-network with the Plan and authorization was 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 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 drug testing provided on February 18, 2021 by an
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 9, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) and bone replacement graft for ridge preservation (D7953) provided on April 22, 2021.
You asked the Plan to pay for the surgical extraction and bone replacement graft. You say that you would like these services to be covered because you are on a strict fixed minimal income. The Plan denied your request. The Plan says these services are not covered under your 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 surgical extraction (D7210) and bone replacement graft for ridge preservation (D7953) provided on April 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital outpatient clinic visit (G0463) knee x-ray (73562) bone/joint studies (77073) provided on April 21, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the outpatient clinic visit. You say that the enrollee presented to orthopedics for complaints of left knee pain. The doctor performed a right total knee on this enrollee previously. When she started to experience pain again, she went back to the original surgeon for evaluation. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 hospital outpatient clinic visit (G0463) knee x-ray (73562) bone/joint studies (77073) provided on April 21, 2021 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided on December 30, 2020.
You asked the Plan to pay for the laboratory test. You say that the charge is for COVID testing and is not
related to hospice care. The Plan denied your request. The Plan says Original Medicare is responsible for
payment.
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 laboratory test provided on December 30, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room visit (99284) provided on August 19,
2020.
You asked the Plan to pay for the emergency room service. You say that the service was medically necessary.
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 emergency room visit (99284) provided on August 19,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue, soft, (D7286) provided
on February 26, 2021.
You asked the Plan to pay for the dental service. You say that this service should be covered. The Plan denied
your request. The Plan says incisional biopsy of oral tissue, soft, is not listed as a covered service. The Plan
also says you did not contact the Plan prior to the date of service to verify 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, the incisional biopsy of oral tissue,
soft, is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay
for the incisional biopsy of oral tissue, soft, (D7286) provided on February 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilling nursing facility (SNF) care provided from
January 23, 2021, to February 21, 2021.

You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare
Act. The Plan denied your request. The Plan says the enrollee did not require skilled services on the dates of
service in this case.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from
trained medical or paramedical staff, is not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the SNF services have not been met. Specifically, we find that the services at issue in this case are
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the skilling nursing
facility (SNF) care provided from January 23, 2021, to February 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services provided on January 17, 2021.
You asked the Plan to pay for the air ambulance services. You say that the air ambulance services were
medically necessary. The Plan denied your request. The Plan says that the enrollee was transported by air
ambulance from the custodial nursing home to the medical center. The closest emergency room facility with
the necessary services would have been 18-minutes by ground ambulance.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your
medical condition is such that transportation by ground ambulance is not appropriate.
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 air ambulance services. Our reviewer
says that the air ambulance services were not necessary. Our physician reviewer found that the enrollee was
transported via air ambulance from a nursing home to the hospital for altered mental status and weakness. She
was somnolent with right-sided weakness. Nearest emergency department facility was 18 minutes away from
the nursing home by ground. The nursing home did not have the facilities necessary for the enrollee. The
enrollee did not present with a condition that contraindications ground transportation. The short time it would
have taken to transport via ground ambulance would have been completely appropriate for this enrollee and
would not have posed any increased threat compared to air transport.
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 air ambulance services have not been met. Therefore, we decided that the
Plan does not have to pay for air ambulance services provided on January 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 17, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on November 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says a review of the current medical literature indicates that this service is considered
experimental and investigational.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the device is experimental. More research is needed to show safety and efficacy of the device.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation provided on February 5, 2021.
You asked the Plan to pay for the limited oral evaluation. You say that you selected this provider because of
their low-cost services. You say that you should not be penalized because the staff used the wrong billing code.
The Plan denied your request. The Plan says the service 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 the
limited oral evaluation provided on February 5, 2021.