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

We decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air
mileage (A0436) provided on July 26, 2021.
You asked the Plan to pay for the rotary wing air transport and air mileage. You say that you believe this
transport meets medical necessity guidelines. The Plan denied your request. The Plan says the service provided
does not meet Medicare guidelines due to the longer time it took for the air ambulance to transport the enrollee.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your
medical condition is such that transportation by ground ambulance is not appropriate.
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 pay for the rotary wing air transport and air mileage.
Our reviewer says that the rotary wing air transport and air mileage was not medically reasonable and
necessary. Our physician reviewer found there is documentation that the patient suffered from an illness or
injury that contraindicated transportation by any means other than ambulance on July 26, 2021. Our reviewer
found that based on the medical records provided there is no documentation that the patient's medical condition
needed immediate and rapid ambulance transport that could not have been provided by ground ambulance and
either the point of pickup was not accessible by ground vehicle or great distances, or other obstacles were
involved in getting the patient to the nearest hospital with appropriate facilities. Our physician reviewer also
found that the records indicate it would have taken a ground ambulance (that was already present on the scene)
46 minutes to transport the patient to the hospital; the air ambulance took 80 minutes (total time) for the same
transport.
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 rotary wing air transport and air mileage have not been met. Therefore, we
decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air mileage
(A0436) provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99213) provided August 16, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the records do not support the procedure 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 99213 is not supported in the medical record. Specifically, the documentation does not
show that the evaluation and management service was separate and distinct from the osteopathic manipulation
service billed. Based on this information, we decided that Medicare rules for coverage of the physician services
have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99213)
provided August 16, 2021.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for an inpatient hospital stay. We decided that the Plan
does not have to waive the copayment for an inpatient hospital stay.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with
these copayments. The Plan says that the correct copayments have been applied.
We decided that the Plan has to reduce the copayment for an inpatient hospital stay.
The Plan has overcharged you based on the 2021 EOC.
Therefore, we decided that the Plan has to reduce the copayment for an inpatient hospital stay.
We also decided that the Plan does not have to waive the copayment for an inpatient hospital stay.
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 $280
copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care.
Dates of Service Correct Total Amount
May 1, 2021 - May 9, 2021 $1,680 ($280 x 6 days)
May 22, 2021 - June 4, 2021 $1,680 ($280 x 6 days)
Total Amount Being Asked to Pay: $3,360 ($1,680 + $1,680 = $3,360)
Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay.
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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to waive the cost-share for the vision services (99213, 92014, 92015) provided
from April 8, 2021, to September 30, 2021.
You asked the Plan to waive the cost-share for the vision services. You say that the facility is sending you bills
that you are not responsible for, and this situation is stressful for you. The Plan denied your request. The Plan
says that these claims were processed correctly, and your appropriate cost-share 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 does not say in clear and accurate terms
how much you should expect to pay for medical vision care.
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20%
coinsurance for medical vision care. The Plan contract states that enrollees must pay 0-20% coinsurance for
medical vision services but does not clarify what exact percentage applies to any specific situation or services.
The contract, as written, states that your cost-share for outpatient physician services for the diagnosis and
treatment of diseases and injuries of the eye may be anywhere from 0% to 20% coinsurance. This means that
the Plan did not follow Medicare rules for disclosure of cost sharing information. In addition, the Plan also
states that one annual routine eye exam is covered at no charge to you, which would include a routine eye
refraction. While the other services may have been non-routine, a refraction is a routine exam by nature and
would be considered a routine eye exam. Therefore, we decided that the Plan has to waive the cost-share for the
vision services (99213, 92014, 92015) provided from April 8, 2021, to September 30, 2021.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the
enrollee from September 1, 2021, to September 17, 2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your
request. The Plan says no daily skilled needs were identified.
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 pay for the services. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found that the enrollee did not require skilled nursing
services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and
effectively provide medically necessary and reasonable treatment in a SNF from 9/1/21 to 9/17/21. The
documentation did not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing
SNF need during these dates. The enrollee's functional level did not require skilled therapy services with the
specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically
necessary and reasonable treatment in a SNF during the dates from 9/1/21 to 9/17/21. The enrollee did not
require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a
SNF during the dates 9/1/21 to 9/17/21. As a practical matter, this enrollee did not require the necessary
services on an inpatient basis, in a skilled nursing facility setting during the 9/1/21 to 9/17/21 period.
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 pay for skilled nursing facility (SNF) services provided to the enrollee from September 1, 2021, to
September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the tissue exam provided on September 17, 2021, by an out-
of-network (OON) provider.
You asked the Plan to pay for the tissue exam. You say that the doctor's office failed to send the
preauthorization form for approval. The Plan denied your request. The Plan says no prior authorization was
obtained.
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. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for a tissue exam provided on September 17, 2021, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) and
additional intraoral periapical x-ray (D0230) provided from September 8, 2021, and September 15, 2021.
You asked the Plan to pay for the periodontal scaling and root planing and additional intraoral periapical x-ray.
You say that you thought you had paid in full for your services. You also say that they did not indicate that you
would have further charges, and then you received statements from the Plan with pending balances. The Plan
denied your request.
The Plan says the periodontal scaling and root planing is not a covered expense under your dental plan. The
Plan also says that your benefits for the additional intraoral periapical x-ray have been satisfied and the
frequency limitation has been exceeded.
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, periodontal scaling and root planing
(D4341) is not among those covered under this benefit. The contract says that intraoral x-rays are limited to one
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220)
on September 8, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan
does not have to pay for the periodontal scaling and root planing (D4341) and additional intraoral periapical x-
ray (D0230) provided from September 8, 2021, and September 15, 2021.
Your complaint about the provider's failure and disclosure of other charges you may have been responsible for
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
You asked the Plan to pre-approve a continuation of SNF care. You say that you are unable to transfer and do not have bed mobility. You say that you cannot walk on your own or do stairs. You say that there is no one at home who can assist you. The Plan denied your request. The Plan says there is no clear benefit of inpatient skilled nursing as opposed to an alternative setting for care.
The Plan says that the specialized skill, knowledge, and judgement of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment. The Plan says that the therapy notes show that the enrollee has achieved the stated goals and was discharged from therapy.
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 a continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF beyond the last covered date. As a practical matter the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
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 stay is medically necessary. The Plan denied your request. The Plan says that your request does not show the enrollee has skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status. The Plan states the services the enrollee requires can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with the enrollee's doctor.
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 physician reviewer found there are identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does require skilled nursing or therapy services on a daily basis. The enrollee does meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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: Transportation
Decision: Favorable

We decided that the Plan has to pay for the transportation services provided on February 17, 2021.
You asked the Plan to pay for the transportation services. You say that this transportation was medically
necessary. You say that the enrollee had tested positive for coronavirus. You also say that the enrollee required
oxygen therapy during transport. The Plan denied your request.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the Plan has not provided any documentation to indicate the
specific services that are at issue in this case or why they are not covered. These documents were requested but
nothing was received. Therefore, we decided that the Plan has to pay for the transportation services provided on
February 17, 2021.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluations provided on May 19,
2021, May 26, 2021, June 9, 2021, June 16, 2021, and June 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychiatric diagnostic evaluations. You say that you were told specifically
that it was an order and not a referral. The Plan denied your request. The Plan says the services received 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. A
Licensed Mental Health Counselor is ineligible for Medicare coverage and is not covered under your plan.
Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluations provided on
May 19, 2021, May 26, 2021, June 9, 2021, June 16, 2021, and June 23, 2021 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 collection of venous blood by venipuncture services
provided on September 14, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the collection of venous blood by venipuncture services. You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided 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 collection of venous blood by venipuncture
services provided on September 14, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee brace (L1851) and suspension sleeve (L2397), provided on September 30, 2021.
You asked the Plan to pay for the knee brace and suspension sleeve. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that knee braces are covered when the criteria in the Medicare Rules section of this letter are 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 pay for the knee brace and suspension sleeve. Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided records do not document a recent injury to or a surgical procedure on the knee(s) or knee instability on physical examination. 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 knee brace and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee brace (L1851) and suspension sleeve (L2397), provided on September 30, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-of-network (OON) provider on August 3, 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 laboratory services (88305, 88312) rendered by the out-of-network (OON) provider on August 3, 2021