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

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve the additional routine transportation mileage. The Plan denied your request.
The Plan says this request exceeds your benefit limits.
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 routine transportation when each one-way trip does not exceed 50 miles of driving
distance.
We looked at your request, the records in the case file, and the rules. The contract says that each one-way trip
cannot exceed 50 miles of driving distance. You have requested to be transported more than 50 miles in a oneway
trip. Based on this information, we decided that the Plan's rules for coverage of routine transportation have
not been met. Therefore, we decided that the Plan does not have to pre-approve additional routine
transportation mileage
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a teeth cleaning (D1110), and a comprehensive oral evaluation (D0150) provided on March 22, 2021.

You asked the Plan to pay an additional amount for a teeth cleaning, and a comprehensive oral evaluation. You say that you were not satisfied with the services you received at the in-network provider, so you chose an out-of-network provider. The Plan denied your request. The Plan says the claim for the teeth cleaning was processed correctly with the applicable out-of-network allowable amount paid. The comprehensive oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every 3 years.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a teeth cleaning, and a comprehensive oral evaluation have not been met. Specifically, the comprehensive oral evaluation is a covered benefit, but the record shows that you had exceeded the frequency limit prior to this service on February 4, 2021.

Additionally, the claim for the teeth cleaning was processed correctly with the applicable out-of-network allowable amount paid. 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 a teeth cleaning (D1110), and a comprehensive oral evaluation (D0150) provided on March 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).

You asked the Plan to pre-approve the interspinous spacer placement. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is not covered at this time.

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 interspinous spacer placement. 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 spinous spacer devices. 

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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from January 1, 2021, to January 26, 2021.

You asked the Plan to waive the copayment for the SNF stay. You say that you should not be liable for the charges. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment per day, days 1-20 for an in-network SNF stay and a $184 copayment per day, days 21-100 for an in-network SNF stay.

You have been asked to pay a $1,602 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) 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 SNF stay provided from January 1, 2021, to January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four periodontal scalings and root planings (D4341 x4).
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says these
services are not covered under the enrollee's benefit 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 pre-approve four
periodontal scalings and root planings (D4341 x4).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, chest (71045) provided August 9, 2019.
You asked the Plan to pay for the diagnostic service. You say that please reprocess the claim for payment based on these extensions in place for COVID-19. The Plan denied your request. The Plan says the claim was received past the timely filing limitation.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the diagnostic service was not filed until February 4, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for radiologic examination, chest (71045) provided August 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on January 11, 2021 by an outof-
network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that you were in a care facility and was unaware
the lab was not contracted with the Plan. The Plan denied your request. The Plan says the provider is out-ofnetwork.
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 laboratory work provided on January 11, 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 a filling (D2392) provided on March 25, 2021.
You asked the Plan to pay for a filling. You say that you cannot afford the balance due to a limited income. The
Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency
limit of two every calendar year.
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 filling have not been met. Specifically, the record shows that you had exceeded the frequency
limit prior to this service on March 3, 2021. Therefore, we decided that the Plan does not have to pay for a
filling (D2392) provided on March 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane 60mg/3ml syringe 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 the step therapy requirements have not been fulfilled.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee is required to try and fail the intra-articular steroid injection - Gel One. The enrollee has not trialed this viscosupplemental treatment. Step therapy, as outlined by the plan, requires that Gel-One be trialed first. The documentation does not outline contraindications or reasons this medication was not considered. Without the support of the documentation, Durolane is not approved as step criteria have not been met. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane 60mg/3ml syringe for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 3, 2021

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says these tests are not covered by Medicare and were performed for screening purposes.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The tests at issue in this appeal, lab tests, were requested for screening purposes. Medicare does not cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on February 3, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on August 13, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you received three medications for the pneumonia, one for your cholesterol and one for the asthma and emphysema. You also say that you were inpatient and feel that these medications should be covered. The Plan denied your request. The Plan says the self-administered drugs requested here are not among the types which are covered by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 pay for the self-administered drugs provided on August 13, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation (A0427) provided on March 31, 2021.
You asked the Plan to waive the copayment for emergency ambulance transportation. You say that you were told the service would be covered and you want the Plan to pay. The Plan denied your request. The Plan says the copayment 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 $225 copayment for ambulance services. You have been asked to pay a $225 copayment for emergency ambulance transportation. The service at issue 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 emergency ambulance transportation (A0427) provided on March 31, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health visits.

You asked the Plan to pre-approve additional home health visits. You say that the additional home health visits are medically necessary. The Plan denied your request. The Plan says the remaining home health visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 additional home health visits. Our reviewer says that additional home health visits are not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the nine approved home health skilled nursing visits would be inadequate to address the enrollee's needs with regard to the Foley catheter and follow-up care after the hospital treatment for pyelonephritis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (90832) provided on February 12, 2021.
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 patients covered under hospital insurance are entitled to have payment made on their behalf for covered extended care services in a skilled nursing facility (SNF). We looked at the file and Medicare rules. In this case, billing POS code 31 means that this was a Part A stay. Part A payment includes medical social services like the ones provided in this case. As such, these services cannot be covered when billed with POS code 31. 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 services (90832) provided on February 12, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on August 20, 2020.
You asked the Plan to pay for the therapeutic activities. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation shows that these services were performed by an occupational therapist assistant in a home health or hospice setting. This means there is a more appropriate code to be billed for the service. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on August 20, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided from January 15, 2021, to January 29,
2021.

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 patients covered under hospital insurance are
entitled to have payment made on their behalf for covered extended care services in a skilled nursing facility
(SNF).

We looked at the file and Medicare rules. In this case, billing POS code 31 means that this was a Part A stay.
Part A payment includes medical social services like the ones provided in this case. As such, these services
cannot be covered when billed with POS code 31. 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
services provided from January 15, 2021, to January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Lyric hearing aid provided on February 17, 2021.

You asked the Plan to pay for the Lyric hearing aid. You say that you tested several different hearing aids and this was the only one to be satisfactory. You say that coverage for the costly investment should be covered for the first year. The Plan denied your request. The Plan says this type of hearing aid is not covered under your Plan.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for only certain types of brands of hearing aids.

We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the Lyric hearing aid have not been met. The Plan informed the provider prior to the purchase that this type of hearing aid was not covered. Therefore, we decided that the Plan does not have to pay for the Lyric hearing aid provided on February 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided on February 26, 2021.
You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on February 26, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on February 2, 2021.
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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit provided. 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 visit provided on February 2, 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 March 10, 2021.
You asked the Plan to waive the copayment for an emergency room visit. You say that you left before having anything done. 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/in-network/emergency services. You have been asked to pay a $90 copayment for an emergency room visit. Once you are signed into an emergency room department, a copayment is applied, regardless of services being provided or not. An emergency room visit falls within the emergency care/in-network/emergency 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 emergency room visit provided by a participating provider on March 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from January 16, 2021 to January 30, 2021.

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 claims were billed incorrectly.

The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. 

We looked at the file and Medicare rules. The file shows that the claims were not billed with the required 032x TOB code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from January 16, 2021 to January 30, 2021.