Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from June 18, 
2021, through June 29, 2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that physical therapy was prescribed 
upon review of the magnetic resonance imaging. You say that the fee for physical therapy seems too high. The 
Plan denied your request. The Plan says the copayments 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 $40 
copayment for each Medicare-covered physical and speech therapy service from an in-network provider. 

You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is 
$160 ($40/visit x 4 visits = $160). Physical therapy falls 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 copayment for physical therapy provided from June 18, 2021, 
through June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program (92002) provided July 19, 2021 by an out-of-network (OON).

You asked the Plan to pay for the eye exam. You say that the provider called to verify benefits and provided a pre-service estimate with a $0 patient responsibility. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider. The Plan additionally says they were unable to find a record that benefits or network status were verified prior to the services and have no recourse for incorrect information provided by an OON provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when obtained from a provider in the Plan's vision vendor network. 

We looked at the file and the Plan's rules. In this case the eye exam was provided out-of-network. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for the ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program (92002) provided July 19, 2021 by an out-of-network (OON).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Aranesp. 

You asked the Plan to pre-approve Aranesp. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires 
a trial of Retacrit before it will approve Aranesp. 
 
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 Aranesp. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Aranesp. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drug of Retacrit. The record does not show that 
this drug would likely be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on June 18, 2021.
You asked the Plan to waive the copayment for the office visit. You say that the physician could not help you so you should be credited your 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 Physician Services, specialist. You have been asked to pay a $40 copayment for the office visit. The office visit falls within the Physician Services, specialist 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 office visit provided on June 18, 2021
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 9, 2021.
You asked the Plan to pay for the physician services. You say that the requested medical records were submitted, and the claim should be reconsidered for payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the physician services provided on January 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted procedure, pelvis or hip joint coded 27299 provided on April 14, 2021

You asked the Plan to pay for the unlisted procedure, pelvis or hip joint. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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. In this case, the CPT Code Manual definition of code 27299 is unlisted procedure, pelvis or hip joint. 

We find that CPT code 27299 is not supported in the medical record. Specifically, this code is on the list of surgical procedures to be excluded from payment in ambulatory surgical centers. Review of the file shows that this service was provided in an ambulatory surgical center. Therefore, this code is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the unlisted procedure, pelvis or hip joint have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted procedure, pelvis or hip joint coded 27299 provided on April 14, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided from March 25, 2021, to June
12, 2021.
You asked the Plan to pay for the diabetic supplies. You say that the services were medically necessary. The
Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in
which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the diabetic supplies provided from March 25, 2021, to June
12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames and lenses provided by an out-of-network provider on May 26, 2021.
You asked the Plan to pay for the frames and lenses. The Plan denied your request. The Plan says out-of-network services were not authorized, and in-network providers were available.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are received from a network provider. We looked at the file and the Plan's rules. The records show you received the frames and lenses from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the frames and lenses have not been met. Therefore, we decided that the Plan does not have to pay for the frames and lenses provided by an out-of-network provider on May 26, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on February 
13, 2021. 
 
You asked the Plan to waive the copayment for the ambulance ride. You say that you disagree with the 
copayment because you had no other choice but to be transported by ambulance. 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 $250 
copayment for each Medicare-covered ground ambulance transport (one-way). 

You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride 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 the 
ambulance ride provided on February 13, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on February 19, 2021.

You asked the Plan to pay for the subsequent hospital care. You say that the medical records and waiver of
liability were submitted. You say that the claim should be reprocessed for payment. The Plan denied your
request. The Plan says Original Medicare is responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the subsequent hospital care provided on February 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from February 26, 2020, to March 16, 2020.
You asked the Plan to pay for the skilled nursing services. You say that it was reasonable for you to believe that there would be coverage for these services because the Plan reached out to the treating facility asking for dates and insurance information. The Plan denied your request. The Plan says this claim was received by the Plan on May 3, 2021, which is after the allowed 12-month timeframe.
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 skilled nursing services was not filed until May 3, 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 the skilled nursing services provided from February 26, 2020, to March 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the porcelain fused to high noble metal crown (D2750) provided on May 20, 2021.

You asked the Plan to reimburse you for the dental service. You say that an exception should be made for coverage. You say that this was medically necessary. You also say that you would like to be reimbursed $129.60, or 30% of what you paid. The Plan denied your request. The Plan says porcelain fused to high noble metal crown is not listed as a covered dental service.

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 crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the porcelain fused to high noble metal crown (D2750) provided on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 8, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like this claim to be reconsidered. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient clinic visits or specialist physician services provided from January 21, 2020, to July 20, 2021.
You asked the Plan to waive the copayments for the outpatient clinic visits and specialist physician services. You say that you should not have any copayments. The Plan denied your request. The Plan says they corrected the copayment amounts, but you are charged the copayments 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 $15 copayment for clinic visits and a $20 copayment for specialist physician services. You have been asked to pay a $15 copayment for clinic services and a $20 copayment for specialist physician 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 copayments for the outpatient clinic visits or specialist physician services provided from January 21, 2020, to July 20, 2021.
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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 There is no documentation provided necessitating admission to a LTACH. 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 wheres he is currently receiving care.There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on April 9, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 subsequent nursing facility care (99309) provided on April 9, 2020, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 16 additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you had a diagnosis of a fall resulting in left elbow fracture on April 13, 2021. You started physical therapy and had 34 visits. The documentation shows that you are making steady progress improving range of motion. Your elbow fracture is improving, and you can do exercises on your own at home. Therefore, you do not meet criteria for the requested 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 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 16 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87502, 
87532, 87541, 87581, 87634, 87640, and 87798 provided on August 4, 2020. 
 
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 billed are not payable. 
 
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 codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 are not 
supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect 
the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory 
specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation 
and/or claim history indicates that the specimen was obtained in a nursing facility place of service 32. Based on 
this information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 
87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 provided on August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), therapeutic parenteral drugs, two or more administrations, different medications (D9612) and removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue (D7530) provided April 6, 2021.
You asked the Plan to pay for the anesthesia, therapeutic parenteral drugs and removal of foreign body from mucosa. You say that the services were necessary. The Plan denied your request. The Plan says these services are not covered under your 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 deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), therapeutic parenteral drugs, two or more administrations, different medications (D9612) and removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue (D7530) provided April 6, 2021.