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

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on October 29, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you tried to go to urgent care, but they were all closed. The Plan denied your request. The Plan says you were charged this copayment 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 $75 copayment for emergency room services. 

You have been asked to pay a $75 copayment for the ER visit. This copayment applies for ER visits, regardless of the reason for the visit. 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 (ER) visit you had on October 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health aide (HHA) services coded as G0156, G0299, G0151, G0155, G0152.
You asked the Plan to pre-approve the home health aide services. You say that you are appealing the Plan's denial because you are in need of the services. The Plan denied your request. The Plan says medical necessity cannot be established for continued HHA level of coverage.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 home health aide services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that
further skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. Provided records do not document any acute or unstable medical conditions or changes in medication or treatment which would necessitate any further skilled nursing visits beyond what have already been approved. No medical notes from the enrollee's treating physician are provided documenting an order or need for additional skilled nursing services. The enrollee's needs at this point appear to be custodial. 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 home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health aide (HHA) services coded as G0156, G0299, G0151, G0155, G0152.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services (99239) provided on June 10, 2021.

You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says only one hospital discharge day management service may be billed per patient per hospital stay.

The Plan must follow Medicare rules. Medicare rules say that only one hospital discharge day management service is payable per patient per hospital stay. 

We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted indicates that another hospital discharge day management service code was billed for the member's hospital stay. It is not appropriate to bill hospital discharge day management services more than once per patient per hospital stay. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services (99239) provided on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a tooth extraction (D7140), an immediate mandibular (D5140), and maxillary (D5130) denture provided by an out-of-network provider on July 2, 2021, to July 20, 2021.

You asked the Plan to pay for a tooth extraction and an immediate mandibular and maxillary denture. You say that your teeth were rotten. You say that this was medically necessary, you did not have a choice. The Plan denied your request. The Plan says the rendered dental services are not covered 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 a tooth extraction (D7140), an immediate mandibular (D5140), and maxillary (D5130) denture provided by an out-of-network provider on July 2, 2021, to July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provide on September 21, 2021.
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a
covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on September
21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, chest (71045) provided September 3, 2021.

You asked the Plan to pay for the diagnostic service. You say that your claim was denied because medical records requested from the provider were not received. You are an invisible provider and do not have access to records requested. Please review and reconsider for payment. The Plan denied your request. The Plan says the explanation of benefits from the primary insurance carrier is needed.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has the provider must first submit the claim to the primary insurance carrier. As the secondary insurer, the Plan cannot be held responsible for the diagnostic service until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for radiologic examination, chest (71045) provided September 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7140), diagnostic consultation (D9310), blood glucose level test (D0412), fillings (D2330, D2140), bitewing x-rays (D0150) and comprehensive oral exam (D0150) provided by an out-of-network provider from July 30, 2021, to October 12, 2021.
You asked the Plan to pay for the dental services. You say that you did not know or understand the condition where you are required to see an in-network provider. You say these services were necessary and your mouth was in bad shape. The Plan denied your request. The Plan says out-of-network dental care is not covered by your plan; the provider in this case is not part of the Plan's network. In addition, some of the services provided are not covered under any circumstances.
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. The Plan does not cover services which are not listed in the dental benefits chart in the contract. If you choose to see an out-of-network provider, you will be responsible for 100% of the cost. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from out-of-network providers are not covered under this benefit. In addition, the diagnostic consultation and blood glucose level test are not listed as covered under this benefit, and there is a maximum of two filling procedures covered per year. Therefore, we decided that the Plan does not have to pay for the extractions (D7140), diagnostic consultation (D9310), blood glucose level test (D0412), fillings (D2330, D2140), bitewing x-rays (D0150) and comprehensive oral exam (D0150) provided by an out-of-network provider from July 30, 2021, to October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scan of the brain to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve MRI services. You say that this imaging service is medically necessary. The Plan denied your request. The Plan says there are in-network providers that would be able to provide this service.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scan of the brain to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) and the laboratory
services (80048, 80076, 85025) rendered by the OON provider on May 10, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were 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 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 hospital outpatient clinic visit (G0463) and the laboratory services (80048,
80076, 85025) rendered by the OON provider on May 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on October 12, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that the ambulance services were medically necessary. The Plan denied your request. The Plan says under Medicare guidelines, your request is not a covered benefit as the transport did not occur.

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 October 12, 2021. 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 ambulance response and treatment, no transport (A0998) provided on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with an allergy specialist on October 6, 2021.

You asked the Plan to waive the copayment for the specialist visit. You say that you went to the doctor to discuss your allergy issue. You feel as though the doctor lectured you about not getting vaccinated and you were not provided a service for your allergy issue. You stated that you should not have to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for specialist visits.

You have been asked to pay a $40 copayment for the specialist visit. This copayment applies for each specialist visit, regardless of your satisfaction with the visit. 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 office visit you had with an allergy specialist on October 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services provided from July 28, 2021, to July 31, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that the social worker at the SNF advised you that the Plan had approved additional SNF days at no cost to you. You said that had you known about these charges, you would never agreed to have the enrollee stay the extra three days. The Plan denied your request. The Plan says this copayment was charged correctly. The Plan says that although it did authorize these additional three days of SNF care, they never advised you that it would be covered 100%.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment for days 1-20, and a $184 copayment per day for days 21-100 for skilled nursing facility care.
Records show that the enrollee was in the SNF for 23 days. She was not charged a copayment for the first 20 days. She has been charged a $184 copayment per day for the last 3 days, for a total of $552. This cost sharing obligation is clearly disclosed in your Evidence of Coverage. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services provided from July 28, 2021, to July 31, 2021.
Your complaint about the social worker at the SNF giving you inaccurate information 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on October 11, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network medical services provided to the enrollee on October 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint (64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (64636) for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that documentation does not show that the enrollee had a minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform previously painful movements after the enrollee's left RFA In January 2021.
The Plan must follow Medicare rules. Medicare rules say that RFA can be covered if Medicare criteria has been met.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The records do not show that the enrollee had a minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform previously painful movements after the left RFA in January 2021. Additionally, the records do not show that the enrollee had a consistent minimum of 80% relief of pain after two MBBs on either side of the lower back. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint (64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (64636) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on September 13, 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 services are not covered.

The Plan must follow Medicare rules. Medicare rules say that for code 62320 to be covered, certain documentation requirements must be met. 

The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the injection rendered on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on October 11, 2021.
You asked the Plan to pay for the special anesthesia service. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99100 has a status indicator of B.
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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). We find that CPT code 99100 is not supported in the record. Specifically, CPT code 99100 has a status indicator of B. This means that the payment for 99100 is always bundled into the payment for another service or procedure. Based on this information, we decided that Medicare rules for coverage of the special anesthesia service have not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia service (99100) provided on October 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 25, 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 services are not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an outpatient hospital setting and should have been billed with POS code 19. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 25, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound (76775) provided on October
1, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered as
you have never had to pay a copayment before. The Plan denied your request. The Plan says the cost-sharing
applied correctly based on the services 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 $100
copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $62.59 copayment for an ultrasound, which is less than the $100 stated in the
Plan's contract. Ultrasounds fall 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 ultrasound (76775) provided
on October 1, 2021.