Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for chiropractic services provided on November 2, 2020, and November 7, 2020.
You asked the Plan to waive the copayments for the chiropractic services. You say that this claim should be paid at 100%. You also said that this claim was during the pandemic, so the Plan should waive the copayments. The Plan denied your request. The Plan says these copayments were charged correctly. The Plan also said that their pandemic-related copayment waiver program was only in effect until September 30, 2020. After October 1, 2020, the enrollee is responsible for normal cost sharing amounts.
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 $20 copayment per visit for chiropractic services.
The enrollee has been asked to pay a $20 copayment per visit for the chiropractic services. The Plan's pandemic-related copayment waiver program ended prior to these services. 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 copayments for chiropractic services provided on November 2, 2020, and November 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ultrasound and a specialist visit provided on April 30, 2021.
You asked the Plan to waive the copayments for an ultrasound and a specialist visit. You say that you disagree with the charges because you were told that you could not be seen anymore and no radiological services took place. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $30
copayment for X-rays. Your contract with the Plan also clearly says that you must pay a $30 copayment for specialist services. The medical records show that you received an ultrasound on April 30, 2021. Therefore, you are responsible to pay the $30 copayment. You had a specialist visit on April 30, 2021. Therefore, you are responsible to pay the $30 copayment. The total amount you owe is: $60. You have been asked to pay the total copayment amount of $60 for an ultrasound and a specialist visit. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 an ultrasound and a specialist visit provided on April 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (84403, 82306, 86140) provided March 19, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were performed for screening purposes and are not eligible for coverage.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The lab testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (84403, 82306, 86140) provided March 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will pay for an inpatient rehabilitation facility (IRF) admission when the services are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per week. The patient does not need to be expected to achieve complete independence in self-care nor be expected to return to his or her prior level of functioning. The patient must need supervision by a rehabilitation physician. The physician must see the patient at least three days per week throughout the stay. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 412.622.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular procedures, implantable, insertable, and 
wearable cardiac device evaluations provided on July 27, 2021. 
 
You asked the Plan to pay for cardiovascular procedures, implantable, insertable, and wearable cardiac device 
evaluations. The Plan denied your request. The Plan says 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 Plan has also 
determined that these services are not urgent or emergent. 
 
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 
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 cardiovascular procedures, implantable, insertable, and wearable 
cardiac device evaluations provided on July 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray of the ribs you had at an outpatient hospital facility on May 14, 2021.
You asked the Plan to waive the copayment for the x-ray. You did not provide an argument in your appeal request. 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 $35 copayment for x-rays. You have been asked to pay a $35 copayment for the x-ray. 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 x-ray of the ribs you had at an outpatient hospital facility on May 14, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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: 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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 present setting where she 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. 
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services coded 88304 and 88305 and 
the special stain including interpretation and report coded 88313 provided on April 23, 2021. 
 
You asked the Plan to pay for the surgical pathology services and the special stain including interpretation and 
report. 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 separately 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 88304, 88305, and 88313 are not supported in the medical record. Specifically, the 
enrollee was inpatient for dates of service April 21, 2021 to April 28, 2021. Payment for these services is 
included in the payment to the facility. This means that these services are not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the surgical pathology services and the special 
stain including interpretation and report have not been met. Therefore, we decided that the Plan does not have 
to pay for the surgical pathology services coded 88304 and 88305 and the special stain including interpretation 
and report coded 88313 provided on April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete 
mandibular denture (D5120) provided on May 17, 2021. 
 
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that 
you would like to be reimbursed $1,000 for your new dentures. The Plan denied your request. The Plan says 
these services are not covered. The Plan also says that the provider's office contacted the Plan on May 17, 2021 
and were advised that the Plan covers preventive benefits only, and there was no mention of dentures on the 
call. 
 
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 
complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) and 
panoramic x-ray (D0330) or pay more for the comprehensive oral evaluation (D0150), and prophylaxis 
(D1110) provided on June 22, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the complete series of intraoral x-rays and panoramic x-ray, and to pay more for 
the comprehensive oral evaluation, and prophylaxis. You say that once the Coronavirus restrictions were lifted 
you were successful in finding a new dental office closer to where you live. You also say that the complete 
series of radiographic images was necessary to ensure the status of your teeth and gums because you were a 
new patient. The Plan denied your request. The Plan says your benefits for the complete series of intraoral x-
rays and panoramic x-ray have been satisfied and the frequency limitation has been exceeded. The Plan also 
says that these services were performed by a non-participating provider, and you are responsible for any 
difference between the Maximum Allowable Fee and the amount the provider bills you for the services. 
 
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, full mouth or panoramic x-rays are 
limited to one procedure code every five years. The record shows that you received a panoramic x-ray on 
February 22, 2019 and your full mouth or panoramic x-rays benefit has been exhausted. You are also 
responsible for the difference between the billed amount and allowed amount for covered dental services that 
are received OON. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral 
x-rays (D0210) and panoramic x-ray (D0330) or pay more for the comprehensive oral evaluation (D0150), and 
prophylaxis (D1110) provided on June 22, 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 coinsurance for a Medicare Part B drug injection provided on June 23, 2021.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you have never been charged in the past and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for Part B drugs. You received a Medicare Part B drug on June 23, 2021. The total allowed amount is $1,837.74 and 20% of that is $367.55.
You have been asked to pay the total coinsurance amount of $367.55 for a Medicare Part B drug injection. A Medicare Part B drug injection falls within the 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 a Medicare Part B drug injection provided on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for optometry services (92012, 92133, 92134) provided March 
9, 2021, to April 27, 2021. 
 
You asked the Plan to pay for the optometry services. You say that the services were medically necessary, and 
you have used this provider in the past. The Plan denied your request. The Plan says vision services are only 
covered when obtained from a contract 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 contract provider. 
 
We looked at the file and the Plan's rules. The services were obtained from an out-of-network provider. Based 
on this information, we decided that the Plan's rules for coverage of the optometry services have not been met. 
Therefore, we decided that the Plan does not have to pay for optometry services (92012, 92133, 92134) 
provided March 9, 2021, to April 27, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on May 5, 2020. 
 
You asked the Plan to pay for the office visit. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says the claim has been filed untimely. 
 
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 office visit was not filed until May 13, 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 office visit (99213) provided on May 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says coverage 
criteria 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. 
Continued SNF services beyond November 10, 2021, were requested. 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 continued services. Our physician reviewer found that from a nursing 
perspective, you received oral medications, had stable vital signs, and were treated for a deep vein thrombosis. 
There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a contact 
guard to minimal assist level for functional mobility. You required varying assist with activities of daily living. 
There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services 
on a daily basis. You do not 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
chest you had on July 30, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were told that this test would be 
free on Medicare.  You said that you don't think it is right that you pay for this insurance but you have to pay 
more than if you didn't have it. 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 $200 
copayment for CT scans.  
 
You have been asked to pay a $200 copayment for the CT scan. This copayment applies regardless of what you 
may pay with Original Medicare. 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 computed 
tomography (CT) scan of the chest you had on July 30, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on June 28, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you do not think you should have to pay this copayment. You stated that you did not want to have an ambulance right from hospital to hospital, and they did not help you while you were in the hospital. 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 $150 copayment per trip for ambulance services. You have been asked to pay a $150 copayment per trip for the ambulance services. This copayment applies regardless of the reason for the ambulance trip. 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 June 28, 2021.