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

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on September 21, 2021.
You asked the Plan to waive the copayment for the urgent care visit. You say that the services should be covered as you didn't know urgent cares could be out of network. 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 $50 copayment for Urgently needed services.
You have been asked to pay a $50 copayment for an urgent care visit. Based on your contract with the Plan, the cost-sharing for urgent care visits applies regardless of the facilities network status. 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 urgent care visit provided on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a second pair of eyeglass frames (V2020) and a single vision
sphere lens (V2100) provided on August 12, 2021.
You asked the Plan to pay for a second pair of eyeglasses and lens. You say that you were told you would be
covered for two pairs of eyeglasses. You also say you would like both claims covered. The Plan denied your
request. The Plan says you are covered for one pair of glasses per calendar year.
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 contract says that you receive a $200 allowance toward the purchase and fitting of
eyeglasses and pair of lenses, one pair, per calendar year.
We looked at the file and the Plan's rules. The records show that you are requesting payment for a second pair
of eyeglasses and lens. The EOC confirms the Plan covers one pair of eyeglasses per calendar year, therefore,
the 2nd pair of eyeglasses are not covered by the Plan. Based on this information, we decided that the Plan's
rules for coverage of eyeglass frame and sphere lens have not been met. Therefore, we decided that the Plan
does not have to pay for a second pair of eyeglass frames (V2020) and a single vision sphere lens (V2100)
provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on September 23, 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 office visit (99203) rendered by the out-of-network (OON) provider on
September 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laryngoscopy, flexible; diagnostic
(31575) and hospital outpatient clinic visit for assessment and management of a patient (G0463) provided
August 25, 2021.
You asked the Plan to waive the copayment for the laryngoscopy and outpatient hospital clinic visit. You say
that you don't feel you should be billed both a specialist and facility fee. The Plan denied your request. The
Plan says the cost sharing 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 $325
copayment for each Medicare-covered outpatient hospital facility visit. The Plan contract also says you must
pay a $50 copayment for each Medicare-covered visit with a specialist.
You have been asked to pay $164.55 for the outpatient hospital clinic visit. This service falls within the
Outpatient hospital services benefit category. You have been asked to pay a $50 copayment for the
laryngoscopy. The laryngoscopy falls within the Medicare-covered visit with a specialist benefit category. This
means that you have been asked to pay less than or equal to 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 laryngoscopy, flexible; diagnostic
(31575) and hospital outpatient clinic visit for assessment and management of a patient (G0463) provided
August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on September 7, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the services provided. You say that the documentation supports the billed code. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
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 file shows that the enrollee was seen for a routine follow-up visit. 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 home visit provided on September 7, 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 a resin-based composite (D2392), and intraoral imaging
(D0220) provided by a participating provider on September 28, 2021.
You asked the Plan to pay for a resin-based composite and intraoral imaging. You say that you think the Plan
should pay for this. The Plan denied your request. The Plan says D2392 and D0220 are not covered dental
benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-
based composite (D2392), and intraoral imaging (D0220) provided by a participating provider on September
28, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy, flexible; diagnostic
(45378) provided August 31, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you do not recall the
provider telling you there was anything diagnostic found in your colonoscopy. 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 $325 copayment for each Medicare-covered
outpatient hospital facility visit.
You have been asked to pay a $325 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy
falls within the Outpatient surgery benefit category. The medical records provided show that that you were
referred for a colonoscopy due to a positive Hemoccult test. This means that the colonoscopy was correctly
billed as a diagnostic colonoscopy, and 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 colonoscopy, flexible;
diagnostic (45378) provided August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for tooth extractions (D7140) provided by an out-of-network provider on October 20, 2021.

You asked the Plan to pay for tooth extractions. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says D7140 is 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 tooth extractions (D7140) provided by a participating provider on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of chiropractic care.
You asked the Plan to pre-approve chiropractic care services. You say that these services are medically
necessary for your condition. The Plan denied your request. The Plan says the chiropractic care you are
requesting is non-covered maintenance care.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance
care.
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 chiropractic care services. Our reviewer
says that the requested chiropractic care is not medically reasonable and necessary. Our physician reviewer
found that you are a 77-year-old man with diagnoses of Subluxation complex (vertebral) of cervical region,
Lumbago with sciatica, unspecified side, and Pain in thoracic spine. The case file contains documentation that
you received six chiropractic treatments from September 2021 to October 2021. Additionally, the enrollee
received the same chiropractic services from January 2015 to August 2021 with a total of 202 visits during that
time frame. Recent chiropractic visits document that "The patient's progress has been slower than expected.
No real improvement has been seen by the patient since her last visit...some improvement.... minor
improvement." At this time, it is reasonable to conclude, based upon the available documentation, that further
clinical improvement cannot be reasonably expected from ongoing care, and that continued chiropractic care is
reasonably considered to be maintenance 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 chiropractic care services have not been met. Therefore, we decided that the
Plan does not have to pre-approve the continuation of chiropractic care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on June 15, 2021,
through June 18, 2021.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not
include a critical care note.
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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the record. Specifically, the documentation submitted does not include a critical care note or indicate the amount of time that was spent rendering the critical care services. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services (99291) provided on June 15, 2021, through June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0220 and D0140) received on September 1, 2021.
You asked the Plan to pay for the services. You say that it is the responsibility of the provider to verify their network status before rendering services. The Plan denied your request. The Plan says the claim was processed appropriately.
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. The x-ray cannot be covered, as the same service was already provided on August 11, 2021. This service can only be covered once per year.
Additionally, the type of exam received in this case - a limited oral evaluation - problem focused - is not covered by the dental plan. Therefore, we decided that the Plan does not have to pay for dental services (D0220 and D0140) received on September 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on June 7, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without transport there is no payable service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on June 7, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on June 7, 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 these services are medically necessary. The Plan denied your request. The Plan says that your medical condition requires further evaluation and treatment in the acute care hospital.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for respiratory failure and coronavirus pneumonia. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy (G6012) provided on
August 27, 2021.
You asked the Plan to waive the coinsurance for the radiation therapy. You say that the services should be
covered as you informed the office you could not afford to pay, and the provider stated they would waive the
costs. The Plan denied your request. The Plan says the coinsurance 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 20%
coinsurance for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a 20% coinsurance for radiation therapy (the allowed amount is $265.08 x 20% =
$53.02). Radiation therapy 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 coinsurance for radiation therapy (G6012)
provided on August 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee's symptoms have improved on this medication. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Orencia for the enrollee.
Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from June 30, 2021, to July 6, 2021.
You asked the Plan to pay for the inpatient hospital services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that for inpatient hospital care Medicare does not count the day of discharge for cost report purposes unless the admission and discharge day are the same day. As a result, the billed number of claimable Medicare patient days for an inpatient hospital stay should not include the discharge date. We looked at the file and Medicare rules. You billed 7 days of inpatient hospital care. However, this inpatient stay lasted from June 30, 2021, to July 6, 2021, which should only be billed as 6 days of inpatient hospital care because Medicare does not count the day of discharge when billing. Based on this information, we decided that
Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from June 30, 2021, to July 6, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology procedures provided on March 19, 2021.
You asked the Plan to pay for the radiology procedures. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, feefor-
service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on March 15, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for radiology procedures provided on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the interrogation device evaluation (93296) rendered by the
out-of-network (OON) provider on August 30, 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 interrogation device evaluation (93296) rendered by the out-of-network (OON)
provider on August 30, 2021.