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

We decided that the Plan does not have to pay for the ambulance service provided on March 21, 2021.
You asked the Plan to pay for the ambulance service. You say that your friend called the paramedics for you
because they were nervous and did not want anything happening to you. You also say that the paramedics
checked you out, you told them you felt pretty normal, and the paramedics agreed with you and left. The Plan
denied your request. The Plan says this service is not covered by Medicare because you were not transported by
an ambulance.
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 March 21, 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 the ambulance service provided on March 21,
2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March
28, 2021, to April 26, 2021.
You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act.
The Plan denied your request. The Plan says the enrollee did not require any skilled services during the dates of
service in this case. The Plan also says that the care could have been provided at a lower level.
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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the SNF care have not been met. Specifically, the enrollee did not receive skilled services during
the dates of service in this case. Therefore, we decided that the Plan does not have to pay for the skilled nursing
facility (SNF) care provided from March 28, 2021, to April 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided March
2, 2021, to March 8, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you would like the Plan
to cover the cost of the hospital stay. 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 $180
copayment per day, days 1-8 of Medicare covered inpatient hospital admissions. You have been asked to pay a total of $720 for the inpatient hospital stay. The inpatient hospital stay falls
within the Inpatient hospital care 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 inpatient hospital stay provided March 2, 2021, to March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 23, 2021 by an out-of-network (OON) 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 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 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 laboratory services provided on February 23, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care.
You asked the Plan to pre-approve inpatient mental health care. You say that the enrollee was admitted per court order. The Plan denied your request. The Plan says the intensity of treatment and the relative freedom of movement afforded to patients are inconsistent with an Acute Inpatient Mental Health treatment setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our reviewer says that the enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. Our physician reviewer found the enrollee was not shown to be a danger to himself or others but was without agitation or aggression without perceptual disturbance including auditory or visual hallucinations. It is not medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than 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 inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services rendered on March 9, 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. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the pain management services rendered on March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on March 2, 2021.
You asked the Plan to pay for the occlusal guard (D9944). You say that the mouth guard was prescribed by the dentist to protect the crown that had to be replaced. You say that this was necessary, and you should be reimbursed. The Plan denied your request. The Plan says the service 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 the occlusal guard (D9944) provided on March 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient mental health stay.
You asked the Plan to pre-approve an inpatient mental health stay. You say that the member was admitted to the facility by the court on a committed 305 order. The Plan denied your request. The Plan says the enrollee does not meet the criteria for inpatient psychiatric care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 an inpatient mental health stay. Our reviewer says that it did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. Our physician reviewer found the enrollee was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. The member was not showing any aggressive behaviors, or any treatment required for acute threats of safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient mental health stay have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient mental health stay.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from October 6, 2019, to October 10, 2019.
You asked the Plan to pay for the services provided. You say that the clinical evidence in the records support the claim for acute respiratory failure. The Plan denied your request. The Plan says the billed diagnoses were not supported by the clinical records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services with diagnosis code J96.01, acute respiratory failure with hypoxia. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services provided. Our physician reviewer found that the enrollee presented to the emergency room with shortness of breath. She had an oxygen saturation of 81%. After 3 minutes, without any intervention, her oxygen saturation increased to 94%. She was admitted and responded to medical treatment. Her condition stabilized and improved. She was then discharged home. The review has determined that the records did not show that the billed diagnosis code, J96.01, was supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from October 6, 2019, to October 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing (D4341 x 2) provided from January 27, 2021, to February 4, 2021.
You asked the Plan to pay for the dental services. You say that you saw this provider in December 2020 and the claim was paid. You also say that if you had known that the provider had opted out of Medicare, you would not have used this provider. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says payment cannot be made to providers who have opted out of Medicare.
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 covers the dental services when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the record shows that the provider in this case has opted out of Medicare. The Evidence of Coverage clearly states that if you use a provider that has opted out of Medicare you will not receive reimbursement. Therefore, we decided that the Plan does not have to pay for the scaling and root planing (D4341 x 2) provided from January 27, 2021, to February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit provided on July 22, 2021 by an
out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the enrollee has been followed for medication
since 2018. 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 medication management. 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 outpatient clinic visit provided on July 22, 2021 by an out-of-network (OON) provider
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 30, 2020 to October 29, 2020.
You asked the Plan to pay for home health services. You say that this is supported by the records. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. In addition to reporting a visit line using the G codes, agencies must report an additional line item with the same revenue code and date of service, reporting one of the three Q codes. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, while a Q code was billed on the claim, it was not billed with the same date of service as a G code as required. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 30, 2020 to October 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities provided on March 17, 2021.
You asked the Plan to pay for the therapeutic activities. You say that the patient was provided medically
necessary healthcare services and the claim was processed incorrectly. You say that the reimbursement rate is
far below what is prescribed in the terms of the plan and it should be processed appropriately. The Plan denied
your request. The Plan says an appropriate modifier was not billed with this code edit.
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, we have confirmed that code 97530
has a bundled relationship with code 92526 and cannot be paid as billed. Specifically, 97530 was not billed
with a modifier to indicate that this service was separate and distinct from 92526. CPT code 97530 cannot be
paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for the therapeutic activities provided on March 17,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 6, 2021 by an out-of-network (OON) 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 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. he 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 laboratory services provided on May 6, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on May 2, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the paramedics had to help you because your blood sugar was low from your diabetes. You also say that you feel this service should be covered. The Plan denied your request. The Plan says the ambulance charges are not covered because there was no transport.
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 May 2, 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 the ambulance response and treatment with no transport (A0998) provided on May 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213), and a partial lower denture (D5214).
You asked the Plan to pre-approve a partial upper denture, and a partial lower denture. You say that you need your dentures replaced because they are broken. The Plan denied your request. The Plan says the services are a covered benefit, but you have exceeded the frequency limit of one every 5 years.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a partial upper denture, and a partial lower denture have not been met. Specifically, the record shows that you had exceeded the frequency limit for these services on January 31, 2019. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213), and a partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sensor (A9276) and a transmitter (A9277) for a continuous glucose monitor.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says these items are not covered by Medicare in any payment system.

The Plan must follow Medicare rules. The rules say that HCPCS A9276 and A9277 are not covered codes. The requested supplies are coded in such a way that makes it statutorily not covered by Medicare. 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 pre-approve a sensor (A9276) and a transmitter (A9277) for a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment and supplies rendered on March 2, 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 procedure code E1399 is not supported and S1015 is not covered.
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 is durable medical equipment, miscellaneous. We find that CPT code is not supported in the medical record. Specifically, the records do not show that equipment was dispensed for home use. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. Billed procedure code S1015 (intravenous tubing extension set) has a status indicator of I and is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the durable medical equipment and supplies rendered on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician evaluation and management services provided on May 21, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the services provided. You say that the service was provided with no adequate time frame to obtain authorization. The Plan denied your request. The Plan says authorization is required for out-of-network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for physician evaluation and management services provided on May 21, 2020, by an out-of-network (OON) provider.
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 May 13, 2021.

You asked the Plan to pay for these services. You say that the enrollee's physician told the enrollee a referral was sent. 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 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 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 May 13, 2021.