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

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on July 2, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services provided to the enrollee on July 2, 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 this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, or home with outpatient therapy.  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 that from a review of the available records, you are medically stable with no complex medical conditions to address. There are no other medical complexities. You do not require physician supervision three times a week in the IRF. There are no acute rehabilitation nursing needs. Based on your current level of function, you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. You need physical and occupational therapy in an alternate and lower intensity level.  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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for two denture tooth replacements (D5520) provided on July 8, 2021.  You asked the Plan to pay for the denture repairs. You say that the provider told you these were covered services and feel you have been misled. The Plan denied your request. The Plan says the denture repair is a covered service, but you are limited to one repair procedure code per year. You received three repairs on the date in question, and one was paid in full. You are responsible for the other two, which exceed the frequency limitation of your dental benefit. The Plan also says that they did discuss whether or not the service is covered with the provider, but limitations on the service were not asked or discussed.    Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan can cover one procedure code for denture adjustments per calendar year.  Though the Plan offers a dental benefit in excess of Medicare coverage, the denture repairs are requested in a frequency that exceeds what is covered under this benefit. Documentation shows that you had three denture tooth replacements provided on the date in question. One was paid in full, which met your benefit limitation for this service for the year. Therefore, we decided that the Plan does not have to pay for two denture tooth replacements (D5520) provided on July 8, 2021.   Your complaint about potential missing information when contacting the Plan regarding covered services 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy rendered on April 1, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.  We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit rendered on March 18, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.      The provider submitted a claim for procedure codes 99211 (office visit) and 96372 (therapeutic, prophylactic, or diagnostic injection). Code 99211 is a column II code with a modifier indicator of 1 when billed with column I code 96372. Code 99211 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the office visit rendered on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on July 12, 2021.  You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that this procedure was covered and paid for the past 2 years. You say that you are wondering if the plan changed and are asking for a fast appeal of the denial. The Plan denied your request. The Plan says dental benefits are only available through the dental rider which was not active at the time of service.    Medicare generally does not cover dental services. The Plan follows the same rule.  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on July 12, 2021. Contact the Plan regarding enrolling in the optional supplemental dental benefits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for additional root canals provided on May 5, 2021.  You asked the Plan to pay for additional root canals. You say that you wouldn't have chosen this plan if the dentist was not covered. You say that you verified that two root canals would be covered, and the services should be paid. The Plan denied your request. The Plan says the claim was reprocessed toward your in-network benefits as a one-time exception.  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, you also have a maximum benefit of one root canal every year from a network provider. The Plan paid for one root canal for tooth #20 provided on May 5, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for additional root canals provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on August 10, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network medical services provided to the enrollee on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation (D7953) provided by a participating provider on July 20, 2021.  You asked the Plan to pay for a bone replacement graft. You say that you were advised that these services were covered. The Plan denied your request. The Plan says the dental services that were provided are not a covered benefit.  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 a bone replacement graft for ridge preservation (D7953) provided by a participating provider on July 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for inpatient hospital services you received from June 8, 2021, to June 11, 2021.  You asked the Plan to reduce the copayment for the inpatient hospital services. You say that you were told when you checked into the hospital that you would only have a $95 copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 $298 copayment per day for days 1-7 for inpatient hospital care.   Records show that you were in the hospital for 3 days.  You were charged a copayment of $298 per day, for a total of $894.  You already paid $95 of this amount, leaving you with a balance of $799. 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 reduce the copayment for inpatient hospital services you received from June 8, 2021, to June 11, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for Esophagogastroduodenoscopy services (43247, 43255 and 43270) provided on May 27, 2021.  You asked the Plan to pay for the Esophagogastroduodenoscopy services. You say that you would like reconsideration because these services were billed appropriately on the claim. The Plan denied your request. The Plan says that these services are bundled into the base endoscopy procedure which was approved and paid.  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 43247, 43255 and 43270 are supported in the record. Specifically, the record does not clearly show that the Plan has paid the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy. Based on this information, we decided that Medicare rules for coverage of the Esophagogastroduodenoscopy services have been met. Therefore, we decided that the Plan has to pay for Esophagogastroduodenoscopy services (43247, 43255 and 43270) provided on May 27, 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: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on June 12, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that you had an accident in the hospital while picking up your son.  You said that the hospital told you they would not charge you or your insurance for this. 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 $90 copayment for emergency room visits.   You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason for the ER visit. 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 emergency room (ER) visit you had on June 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a walker purchased online on June 18, 2021.  You asked the Plan to pay for durable medical equipment from commercial retailers. You say that the Plan should pay for this walker. The Plan denied your request. The Plan says this retailer is not a Medicare eligible provider and you did not have prior authorization to purchase this equipment.  The Plan must follow Medicare rules. The rules say that enrollees must use Medicare eligible providers. The Plan contract says that durable medical equipment requires prior authorization. This equipment was purchased online without prior authorization. Therefore, we decided that the Plan does not have to pay for a walker purchased online on June 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for computed tomography (CT), thorax, low dose CT for lung cancer screening, without contrast material(s) (71271) provided on May 24, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the diagnostic service. You say that you disagree with this denial as there are no LCD or NCD policies for this combination of procedure and diagnosis for this enrollee's services. The Plan denied your request. The Plan says the enrollee does not meet the criteria. Enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter. 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. This service is only covered for people ages 55-77 years of age and the enrollee was 80 years of age on the date of service. 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 computed tomography (CT), thorax, low dose CT for lung cancer screening, without contrast material(s) (71271) provided on May 24, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on June 23, 2021 by a non-network provider.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-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 requested provider in this case is not a network provider with the Plan. The referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 23, 2021 by a non-network provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 13, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the claim was not coded correctly.  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 the various denied codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 laboratory services provided to the enrollee on January 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Gimoti.  You asked the Plan to pre-approve Gimoti. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gimoti.   Benefits for Gimoti may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services from April 12, 2021, to April 14, 2021, and from April 14, 2021, to April 26, 2021.  You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that the inpatient stay was incorrectly processed as out-of-network. The Plan denied your request. The Plan says the claims have been reprocessed as in-network and the copayment has been 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $325 copayment per day, days 1-6 for inpatient hospital care.   The enrollee has been asked to pay a total of $650 ($325 copayment x 2 days = $650) for the inpatient stay from April 12, 2021, to April 14, 2021, and $1,950 ($325 x 6 days = $1,950) for the inpatient stay from April 14, 2021, to April 26, 2021. The inpatient rehabilitation services fall within the Inpatient hospital care benefit category. 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 inpatient rehabilitation services from April 12, 2021, to April 14, 2021, and from April 14, 2021, to April 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for non-emergency transportation, wheelchair van (A0130) provided on July 7, 2021.  You asked the Plan to pay for non-emergency transportation, wheelchair van. The Plan denied your request. The Plan says transportation by wheelchair van is a contract exclusion and not a covered benefit.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services.   The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for non-emergency transportation, wheelchair van (A0130) provided on July 7, 2021.