Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee would not benefit from a LTACH care.

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 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 he is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on October 22, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the drug testing. You say that the Plan's benefit representative told you the provider was in-network. The Plan denied your request. The Plan says the provider is out-of-network.

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 drug testing provided on October 22, 2020 by an out of network (OON) provider.

Your complaint about the Plan's gross negligence is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on June 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained y the member's primary care physician.

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 lab work provided on June 18, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on pages 46 and 49 of the Plan's 2020 Evidence of Coverage (EOC).

You asked the Plan to pay for a mammogram. You say that you would like this reprocessed and paid due to medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for these services.

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 a mammogram provided on December 15, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug provided on June 23, 2020.

You asked the Plan to waive the coinsurance for the Part B drug. You say that your coinsurance should have been waived due to Covid-19. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each in-network Medicare-covered Part B drug.

You have been asked to pay $211.20 which is 20% of the allowed amount for the Part B drug. The allowed amount is $1,056. ($1,056 x 20% = $211.20). The Part B drug falls within the "Medicare Part B prescription drugs" benefit category. The Plan says the Covid-19 cost sharing waiver only applies to primary care professional services.

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 coinsurance for the Part B drug provided on June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Contour Next test strips.

You asked the Plan to provide coverage for Contour Next test strips. You say that you prefer to use the requested brand of test strips. The Plan denied your request. The Plan says the requested brand is not covered under the Plan benefit. The Qualified Independent Contractor (QIC) partially overturned the Plans denial. The Plan requested a reopen and stated that the QIC did not apply the correct coverage criteria.

The Plan is correct in this case. This is not a medical necessity issue. This is a contractual coverage issue. The rules say a Plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as benefit limitations, copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you will have zero-dollar cost share for diabetic supplies when you use the Plans contracted brands. The Plan is not obligated to waive the contractual rules if you choose to use a brand of test strips not covered by the Plan. Therefore, we decided that the Plan does not have to provide coverage for Contour Next test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine preventative visit (99397) provided February 18, 2021.

You asked the Plan to pay for the routine preventative visit. You say that this service was a routine women's health visit and should be covered. The Plan denied your request. The Plan says the code billed is not covered.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months.

Based on review of the file, the services provided are beyond the services included in the covered Annual Wellness visit. The code billed for the routine physical is excluded from Medicare payment. Therefore, we decided that the Plan does not have to pay for a routine preventative visit (99397) provided February 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provide on December 2, 2020.

You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place by the medics then triaged to BLS for transport. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on December 2, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider on December 4, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that you do not feel like you owe 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 $270 copayment for ambulance services/in-network. 

You have been asked to pay a $270 copayment for ambulance services. The correct copayment has been applied to the services that were provided. Ambulance services fall within the ambulance services/in-network 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 ambulance services provided by a participating provider on December 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingival flap procedure, including root planing (D4241) provided on October 26, 2020.

You asked the Plan to pay for gingival flap procedure, including root planing. You say that you do not understand why the services with this provider would not be covered. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.

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 gingival flap procedure, including root planing have not been met. Specifically, services were provided by an Opt out provider. The Plan does not cover dental services when provided by an Opt out provider. Therefore, we decided that the Plan does not have to pay for gingival flap procedure, including root planing (D4241) provided on October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided January 13, 2021.

You asked the Plan to pay for the complete series of intraoral x-rays. You say that x-rays were covered last year and should be covered this year. The Plan denied your request. The Plan says there is no coverage for this service under your dental 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 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 intraoral - complete series of radiographic images (D0210) provided January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for physician services, an x-ray and injection
provided by an out-of-network provider on May 6, 2019, to May 21, 2019.

You asked the Plan to waive the deductible for physician services, an x-ray and injection. You say that this is a
financial burden for you. The Plan denied your request. The Plan says the correct deductible amount has been
applied.

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 $1,000 deductible for what is your plan deductible.

The item or service you asked the Plan to waive the deductible for falls within the benefit category what is your
plan deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a
$1,000 deductible for what is your plan deductible. This cost sharing is a contractual obligation that had not
been met at the time physician services, an x-ray and injection was received on May 6, 2019 to May 21, 2019.
The total amount you are being asked to pay is $354.58. Therefore, we decided that the Plan does not have to
waive the deductible for physician services, an x-ray and injection provided by an out-of-network provider on
May 6, 2019, to May 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from
January 6, 2021, to January 19, 2021.

You asked the Plan to waive the copayments for the physical therapy visits. You say that the physical therapy
was post-operative from a total knee replacement and medically necessary. 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 $30
copayment for each Medicare-covered physical therapy and/or speech and language pathology visit.

You have been asked to pay a $30 copayment for the physical therapy visits on each date of service. The
physical therapy visits fall within the "Outpatient rehabilitation 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 copayments for the physical therapy visits provided from January 6, 2021, to
January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair services provided on December 14, 2020.

You asked the Plan to pay for the services provided. You say that the manufacturer directed you to their repair facility. The Plan denied your request. The Plan says services cannot be reimbursed from a provider that is not certified with Medicare.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that while you can get your care from an out-of-network provider, the provider must be eligible to participate in Medicare.

The file shows that you received repairs to your continuous positive airway pressure (CPAP) device. The provider in this case is not a network provider with the Plan and is not eligible to provide services under Medicare. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the repair services provided on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster vaccine you received on January 4, 2021.

You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not covered under your Part C plan.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. 

The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the Zoster vaccine you received on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a complete intraoral series of radiographic images (D0210) provided on February 8, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, and a complete intraoral series of radiographic images. You say that you were not aware that you had to use a contracted provider. The Plan denied your request. The Plan says The Plan says you are not covered for these services when they are rendered 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 comprehensive oral evaluation, and complete intraoral series of radiographic images have not been met. Specifically, services were provided by an out-of-network provider. 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 comprehensive oral evaluation (D0150), and a complete intraoral series of radiographic images (D0210) provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on September 17, 2020.
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 procedure code 99205 is not supported.
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 99205 is Level 5 outpatient visit for evaluation and management of new patient with problem of moderate to high severity, including comprehensive history and physical examination, and medical decision-making of high complexity, typical time with patient and family 60 minutes. We find that CPT code 99205 is not supported in the medical record. Specifically, there is no documentation of total time for the encounter. 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 office visit rendered on September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames (V2020), sphere, single vision, plano to plus or minus 4.00, per lens (V2100), and vision item or service, miscellaneous (V2799) provided April 20, 2019.

You asked the Plan to pay for the frames and lenses. You say that you were told the eyeglasses could be reimbursed. The Plan denied your request. The Plan says routine eye wear was not part of your vision benefits.

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.

Though the Plan offers a vision 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 frames (V2020), sphere, single vision, plano to plus or minus 4.00, per lens (V2100), and vision item or service, miscellaneous (V2799) provided April 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided by an out-of-network provider on December 11, 2020.

You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services were not approved in advance.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the drug testing services provided by an out-of-network provider on December 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 23, 2020.

You asked the Plan to pay for the ambulance services. You say that The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services on November 23, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 23, 2020.