Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings provided on April 14, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the compression stockings. You say that you were unaware that these would be denied if they weren't received from a contracting provider. The Plan denied your request. The Plan says that the compression stockings weren't received from a network 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 compression stockings provided on April 14, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99204) provided on April 16, 2021.
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as you were inpatient. 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 $40 copayment for Physician/Practitioner services, including doctor's office visits, specifically specialist office visits.
You have been asked to pay a $40 copayment for an office visit. The record indicates that these services were provided while you were still considered outpatient in the hospital. 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 office visit (99204) provided on April 16, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for emergency room (ER) visits provided from August 4, 2021, to August 15, 2021.
You asked the Plan to waive the copayments for The ER visits. You say that you needed the full set of rabies shots and the only place you could get them was at the emergency room. The Plan denied your request. The Plan says you have been charged 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 $110 copayment for each emergency room visit. The file shows that you had three emergency room visits from August 4, 2021, to August 15, 2021. Therefore, you have been asked to pay a $110 copayment for each emergency room visit. The total for the three visits is
$330 ($110 copayment x 3 visits = $330). The ER visits fall within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for emergency room (ER) visits provided from August 4, 2021, to August 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance oxygen supplies (procedure code A0422) provided to the enrollee on May 19, 2021.
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. The Plan says payment is not allowed for the oxygen supplies, because the services during transport aren't allowed separately.
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 A0422 is "Ambulance (als or bls) oxygen and oxygen supplies, life sustaining situation." We find that CPT code A0422 is not supported in the medical record. Specifically, oxygen received during transport is never paid separately. The code has a status indicator of "X" which indicates that it is statutorily excluded from payment. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for ambulance oxygen supplies (procedure code A0422) provided to the enrollee on May 19, 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 based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and palliative treatment of dental pain (D9110) provided on September 7, 2021.
You asked the Plan to pay for the dental services. You say that the services should be covered. You say that the treatment stopped your pain. You also say that you are on a limited budget and cannot pay this bill. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan also says that palliative treatment of dental pain is not listed as a covered service either.
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 limited oral evaluation and palliative treatment of dental pain are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and palliative treatment of dental pain (D9110) provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99350) rendered by the out-of-network (OON) provider on July 9, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service 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 this service. Therefore, we decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99350) rendered by the out-of-network (OON) provider on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam rendered on July 26, 2021.
You asked the Plan to waive the copayment for these services. You say that the services were for a routine eye exam. 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 $45 copayment for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye.
Review of the file shows that you received an eye exam on July 26, 2021. You have been asked to pay a $45 copayment for these services. These services fall within the Medicare-covered exam to diagnose and treat diseases or conditions of the eye 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 eye exam rendered on July 26, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglass frames and sales tax (V2020, S9999) provided on December 17, 2019.
You asked the Plan to pay for the vision services. You say that these services were necessary. The Plan denied your request. The Plan says this claim was filed more than one year from the date of service. You must submit claims to the Plan within one year from the date you received the service or item. This claim was untimely, and these services are denied.
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 vision services was not filed until July 1, 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 eyeglass frames and sales tax (V2020, S9999) provided on December 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement procedure (22869).
You asked the Plan to pre-approve the interspinous spacer placement procedure. You say that this procedure is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is non-covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the interspinous spacer placement procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is experimental. More research is needed to show safety and efficacy.
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 interspinous spacer placement procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement procedure (22869).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services rendered on September 13, 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 $90 copayment for each emergency care visit.
Review of the file shows that you received emergency room services on September 13, 2021. Per the contract with the Plan, there is a $90 copayment for each emergency care visit. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $65.92. Given that the allowed amount was less than the $90 copayment, you have been asked to pay $65.92 for these services. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) services rendered on September 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgical treatment of the retina (67145) provided on June 24, 2021.
You asked the Plan to waive the copayment for the surgical treatment. You say that the enrollee was not aware that this was considered a surgical procedure and expected a lesser copayment for this treatment. The Plan denied your request. The Plan says this claim was processed correctly, and the copayment was assessed in accordance with the enrollee's contract.
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 $350 copayment for outpatient surgical services.
The enrollee has been asked to pay a $350 copayment for the surgical treatment. The provided treatment billed with procedure code 67145 is classified as a surgical procedure and was provided in an outpatient setting. 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 the surgical treatment of the retina (67145) provided on June 24, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the skilled nursing facility (SNF) services provided from May 1, 2021 to May 12, 2021.
You asked the Plan to waive the copay for the SNF services. You say that you would like these charges waived. The Plan denied your request. The Plan says that you are responsible for the copayment.
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 $20 copay per day for days 1-20 of SNF care. You have been asked to pay a $240 copay for the SNF services. The SNF services fall within the days 1-20 of SNF care 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 copay for the skilled nursing facility (SNF) services provided from May 1, 2021 to May 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your
care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for an emergency room visit and related services (99285, 95819, J7512, G0378) provided from July 6, 2020, to July 10, 2020.
You asked the Plan to pay for an emergency room visit and related services. You say that this was billed correctly. The Plan denied your request. The Plan says that this must be billed with type of bill 131 instead of 137.
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 rules also say that a final digit of 7 in a type of bill code is used to indicate the claim has been submitted to correct a previously submitted bill. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has stated that this claim needs to be billed with type of bill 131 instead of 137, but the records indicate that the claim at issue is a correction to a previously submitted claim. The Plan has not provided an explanation or documentation showing why billing type of bill 137 is not appropriate in this case. Therefore, we decided that the Plan has to pay for an emergency room visit and related services (99285, 95819, J7512, G0378) provided from July 6, 2020, to July 10, 2020.
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: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), and bitewing x-ray (D0270) provided on September 1, 2021.
You asked the Plan to pay for the dental services. You say that your electric toothbrush removed your crowns. You say that the dentist was able to fix one crown but not the other. You also say that you should not be responsible for this bill. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that 1 set of bitewing x-rays are covered per calendar year. The Plan says that 1 periapical x-ray is covered per calendar year. The Plan also says these frequency limits have 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, the limited oral evaluation is not
among those covered under this benefit. Additionally, though bitewing x-rays and periapical x-rays are listed as
a covered service, the frequency limits have been exceeded. The record shows that the Plan paid for a set of
bitewing x-rays and a periapical x-ray that you received on March 22, 2021. Therefore, we decided that the
Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), and bitewing x-ray
(D0270) provided on September 1, 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 based on the medical records provided you do
not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term
care facility on a part time basis appear appropriate in this case.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammography, including CAD when performed (77066) provided March 30, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that this service should be considered preventative. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage
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 $50 copayment for all other Medicare covered outpatient diagnostic tests. You have been asked to pay $50 copayment for the diagnostic service. the diagnostic service falls 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 the diagnostic mammography, including CAD when performed (77066) provided March 30, 2021.