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

We decided that the Plan does not have to waive the copayment for ambulance services you received on April 26, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you don't think you should have to pay this copayment because you didn't call for the ambulance. You said that your provider called for the ambulance when you had a heart complication during cataract surgery. 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 $225 copayment for ambulance services. 

You have been asked to pay a $225 copayment for the ambulance services. This copayment applies regardless
of who call for the ambulance. 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 you received on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services represented by code 00813 provided on April 8, 2021.

You asked the Plan to pay for code 00813. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that code 00813 is not supported in the medical record. Specifically, in order for anesthesia services to be paid, the code must be billed with the appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services represented by code 00813 provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Shingles vaccine provided on January 6, 2021.

You asked the Plan to pay for the Shingles vaccine. You say that you paid upfront for this service and feel you
should be reimbursed. The Plan denied your request. The Plan says the services received are not a covered
benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles
vaccine. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the Shingles
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine provided on January
6, 2021.

Benefits for the Shingles vaccine 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on June 7, 2021, by a provider who
has opted out of Medicare.
You asked the Plan to pay for dental services. You say that you did not know that the provider was not innetwork.
The Plan denied your request. The Plan says rules for payment have not been met because the
provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental
services provided on June 7, 2021, by a provider who has opted out of Medicare.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ultrasound exam of the head and neck (76536) and the computed tomography of the abdomen and pelvis; with contrast material (74177) provided on September 9, 2020 and October 30, 2020.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 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 $100 per day, for a Medicare-covered ultrasound and $250 per day, for other Medicare-covered diagnostic radiology services.

You have been asked to pay $350 which includes a $100 copayment for the Medicare-covered ultrasound and a $250 copayment for the other Medicare-covered diagnostic radiology service 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 copayments for the ultrasound exam of the head and neck (76536) and the computed tomography of the abdomen and pelvis; with contrast material (74177) provided on September 9, 2020 and October 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (62370) provided on April 20, 2021.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent. There were network providers available.
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 service 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 surgical services (62370) provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00811, 99100) provided on April 14,
2021.
You asked the Plan to pay for anesthesia services. You say that this was billed correctly. The Plan denied your
request. The Plan says this was not billed with an appropriate primary diagnosis.
The Plan must follow Medicare rules. Medicare rules say that when the original treatment plan is not carried
out, providers should sequence the condition, which occasioned the admission to the hospital as the principal
diagnosis.
We looked at the file and Medicare rules. The primary and only diagnosis billed on this claim was Z53.8,
procedure and treatment not carried out for other reasons. This is not a valid primary diagnosis, as the primary
diagnosis should be the condition that caused the enrollee's admission.
Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been
met. Therefore, we decided that the Plan does not have to pay for anesthesia services (00811, 99100) provided
on April 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says current needs do not appear to be skilled in nature.

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 the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there are no documented home health physical therapy needs. The enrollee is functioning at a level commensurate with a lower level of care, such as outpatient therapy or a home exercise program. As such, the requested ongoing home health services are not reasonable or necessary. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection you received on April 29, 2021.

You asked the Plan to waive the coinsurance for the Prolia injection. You say that you weren't charged for this drug in prior years. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan also confirmed that you were charged this same coinsurance in 2019 and 2020.

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 20% coinsurance for Medicare Part B drugs. 

You have been asked to pay 20% coinsurance for the Prolia injection. The Prolia injection falls within the Medicare Part B drugs 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 coinsurance for the Prolia injection you received on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 7, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services. 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 laboratory services provided on April 7, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crowns (D2750), pontics (D6240) and retainer crown (D6750).
You asked the Plan to pre-approve the crowns (D2750), pontics (D6240) and retainer crown (D6750). You say that the tooth is black because of all the work done and the crown needs to be replaced. The Plan denied your request. The Plan says the criteria for coverage has not been met.
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 covers the crowns (D2750), pontics (D6240) and retainer crown (D6750) when the services are medically necessary and reasonable.
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 crowns (D2750), pontics (D6240) and retainer crown (D6750). Our physician reviewer found that there are several missing posterior teeth, including #13 and #14 being requested for the appliance. Our reviewer says that given the Plan limitations on there being no missing posterior teeth, a bridge would not be considered medically necessary under these criteria. Our physician reviewer found that tooth #15 is part of an existing bridge and there is not any deficit or decay that would make #15 non-serviceable. Our reviewer says that the provided x-ray of #25 does not clearly show any significant breakdown of structure that would require the support of a crown restoration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns (D2750), pontics (D6240) and retainer crown (D6750) have not been met. Therefore, we decided that the Plan does not have to pre-approve the crowns (D2750), pontics (D6240) and retainer crown (D6750).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for you. The Plan denied your request. The Plan says that medical necessity rules for SNF care have not been met.

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 pre-approve SNF care. Our reviewer says that the requested SNF care is medically reasonable and necessary in this case. Our physician reviewer found that you do not have documented skilled nursing needs, though monitoring of your pain and mood is reasonable. However, you do have documented skilled therapy needs to improve your strength, endurance, and safety. A brief period of daily skilled services is medically necessary and reasonable to establish a maintenance program and/or to prevent deterioration of your condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient mental health care provided from August 4, 2020, through August 11, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the 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 $587 copayment per day, for days 1 to 3 and a $0 copayment per day, for days 4 to 90 for inpatient mental health care.

You have been asked to pay $1,761 ($587 copayment x 3 days) for the inpatient mental health care 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 inpatient mental health care provided from August 4, 2020, through August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (99601) provided March 8, 2021.
You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99601 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, the CPT code billed has a status indicator of "I" and is not valid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (99601) provided March 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing
needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a
maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can
be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ophthalmologist office visit on June 4, 2021.

You asked the Plan to waive the copayment for an ophthalmologist office visit. You say that you thought the pre-cataract surgery exam was included in the outpatient surgery copayment. The Plan denied your request. The Plan says the correct copayment was 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 $40 copayment for each specialist visit for Medicare-covered services. 

You have been asked to pay $30.33 for an ophthalmologist office visit. An ophthalmologist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay less than or equal to 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 ophthalmologist office visit on June 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient diagnostic testing rendered on March 11, 2021.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. 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 $50 copayment for all other Medicare-covered outpatient diagnostic tests.

Review of the file shows that you received a diagnostic mammogram on March 11, 2021. You have been asked to pay a $50 copayment for these services. These services fall within the all other Medicare-covered outpatient diagnostic tests 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 outpatient diagnostic testing rendered on March 11, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90837) provided March 29, 2021.

You asked the Plan to pay for the psychotherapy services. You say that this appeal should be granted because the services provided was medically necessary and meet all applicable professionally recognized standards of healthcare. The Plan denied your request. The Plan says there was no documented contact with the attending/primary care physician. There is no referring physician listed on the claim.

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. We looked at the file and Medicare rules. The submitted claim does not include a referring provider for the services at issue. 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. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy services (90837) provided March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on December 10, 2020.

You asked the Plan to pay for ophthalmological services. The Plan denied your request. The Plan says you
have no out-of-network Plan benefits to reimburse for the services rendered.

Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers
these services when provided by a Plan optical provider.

We looked at the file and the Plan's rules. The file shows that the ophthalmological services were not provided
by a Plan optical provider. Based on this information, we decided that the Plan's rules for coverage of
ophthalmological services have not been met. Therefore, we decided that the Plan does not have to pay for
ophthalmological services provided on December 10, 2020.