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

We decided that the Plan does not have to pay for a measles, mumps, and rubella (MMR) vaccine provided on
December 4, 2020.
You asked the Plan to pay for the MMR vaccine under Medicare Part B. You say that this vaccine should be
covered by the Plan. The Plan denied your request. The Plan says this vaccine is covered under Medicare Part
D.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the MMR vaccine
under Medicare Part B. The Plan follows the same rules. The records do not show that you have been injured or
directly exposed to any illness related to the MMR vaccine under Medicare Part B. Therefore, we decided that
the Plan does not have to pay for a measles, mumps, and rubella (MMR) vaccine provided on December 4,
2020.
Benefits for the MMR vaccine under Medicare Part B 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 physician services rendered on December 16, 2020.
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 provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the physician services rendered on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $325 copayment charged for an outpatient clinic visit and
durable medical equipment provided on April 5, 2021.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The
Plan denied your request. The Plan says this copayment was charged based on the claim submitted by the
provider and the Plan contract agreement.
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 $325 for
outpatient hospital or clinic visits. 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 $325 copayment charged
for an outpatient clinic visit and durable medical equipment provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injection of botulinum toxin type A (CPT code J0585) provided on March 9, 2021.
You asked the Plan to waive the coinsurance for the injection. You say that you were told in March over the phone by one of the Plan's representatives that you had full coverage for the entire year for these shots. The Plan denied your request. The Plan says their pharmacist called you on March 5, 2021, and March 12, 2021, to notify you that the Plan had approved the coverage of this service. The Plan states at no time you were told this would be covered in full, nor was the cost for this drug discussed by the you or our pharmacist.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you received an injection of botulinum toxin type A (CPT code J0585) on March
9, 2021. You have been asked to pay 20% coinsurance of the allowed amount for prescription drugs. The allowed amount is $3,031.50. The total you owe is $606.30 ($3,031.50 x 20% = $606.30). Your 2021 EOC states that enrollees must pay 20% coinsurance for all other Part B drugs. 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 the injection of botulinum toxin type A (CPT code J0585) provided on March 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 home health skilled nursing visits.
You asked the Plan to pre-approve 5 home health skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 5 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. Five home health skilled nursing visits are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 5 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 home health skilled nursing visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued services at a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee is reporting very high blood pressure numbers. The Plan denied your request. The Plan says the criteria for an extended admission were not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting, beyond the last covered date. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued services at a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physicians services provided to the enrollee on July 13, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says prior authorization was not given for this service.
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 physicians services provided to the enrollee on July 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on May
20, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 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 services provided by an out-of-network provider on May 20,
2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review has determined that the documentation does not support that the Keytruda is medically reasonable and necessary for the enrollee. The documentation does not support that the Keytruda is safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation (A0428, A0425) provided on March 26, 2021.

You asked the Plan to pay for ambulance transportation. You say that this was medically necessary. The Plan denied your request. The Plan says this is not separately payable from the enrollee's inpatient stay.

The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services, including transportation services, furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.

We looked at the file and Medicare rules. The record shows that the enrollee was an inpatient at the time the service at issue is provided. That means that this service must be furnished directly by the hospital or billed through the hospital under arrangements and is not separately payable from the inpatient stay. Based on this information, we decided that Medicare rules for coverage of ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transportation (A0428, A0425) provided on March 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary The Plan
denied your request. The Plan says that your rehab and medical needs can be met with part-time skilled
services in a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request.
The Plan says rules for SNF care 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.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you are an 83-year-old male with a past
medical history of heart failure, diabetes, hypothyroidism, subarachnoid hemorrhage and multiple other
medical conditions who is living in his private home and receiving home health services. While there are no
identified skilled nursing needs, there are identifiable skilled therapy needs. In addition, basic skilled services
are not required on a daily basis. In conclusion, based on the medical records provided you do not require the
services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a
part time basis appear appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on May 10, 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 a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a PC/TC indicator of 3 and no PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for the initial intraoral x-ray (D0220), two-film bitewing x-rays (D0272), and unspecified preventative procedure (D1999) provided on June 2, 2021.
You asked the Plan to hold you harmless for the dental services. You say that these services should be covered by your Plan, and you have no other way to pay for them. The Plan denied your request. The Plan says that you have met your benefit limit for all three services, and therefore you are responsible for the cost.
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 preventative dental services for adults, one initial periapical x-ray and up to 5 additional periapical x-rays per year; one single film bitewing x-ray and one two-film bitewing x-ray per year. The rules also say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.
In this case, the Plan denied all three services on the basis that you have exceeded your benefit limitations for the current year. On the date in question, it appears that you had a periodic evaluation, cleaning, the two-film set of bitewing x-rays, one initial periapical x-ray, five additional periapical x-rays, and the unspecified preventative procedure. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has stated that you have met your benefit limitations for these services, but based on the information provided, you have been given one initial periapical x-ray, five additional periapical x-rays, and one two-film bitewing x-ray. There is no documentation that you have had any of these services previously this year. In addition, there does not appear to be a limit on the unspecified preventative dental services for adults. Because the Plan has not forwarded necessary documentation to show that you have exceeded your benefits for these services, we decided that the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to hold you harmless for the initial intraoral x-ray (D0220), two-film bitewing x-rays (D0272), and unspecified preventative procedure (D1999) provided on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the complete upper denture provided on March 15, 2021.
You asked the Plan to pay for the complete upper denture. You say that PPO plans do not require prior
authorization or referral for out-of-network services. You say that the Summary of Benefits shows 50%
coinsurance for dentures or bridges out-of-network and the denial should be reversed. The Plan denied your
request. The Plan says that out-of-network dental services are not covered.
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 complete
upper denture once every five years.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the complete upper denture have been met. Specifically, the Evidence of Coverage clearly says that
out-of-network dental services are covered at 50%. Since the Evidence of Coverage does not state that payment
is based on a network rate you will be reimbursed 50% of the billed amount. (50% x $875 = $437.50).
Therefore, we decided that the Plan has to pay $437.50 for the complete upper denture provided on March 15,
2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on March 2, 2021.
You asked the Plan to pay for non-emergency ambulance transport and ground mileage. You say that the requested ambulance services were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for ambulance services have not been met.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergency ambulance transport and ground mileage. Our reviewer says that the ambulance services at issue were not medically necessary in this case. Our physician reviewer found that the enrollee was transported via ambulance for a scheduled wound care appointment. The enrollee was not treated while transported and there was no incident. The documentation does not support that other means of transport (such as stretcher van) were contraindicated for the enrollee on
March 2, 2021, nor that the enrollee needed the expertise, services, and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The documentation does not support that the ambulance transport on March 2, 2021, was medically reasonable and necessary for the enrollee as the enrollee was stable and could have used a stretcher van safely for this non-emergent trip. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergency ambulance transport and ground mileage have not been met. Therefore, we decided that the Plan does not have to pay for non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a TDAP vaccine provided on May 4, 2021.
You asked the Plan to pay for a TDAP vaccine under Medicare Part B. You say that this vaccine should be covered. The Plan denied your request. The Plan says this vaccine is covered under Medicare Part D.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a TDAP vaccine under Medicare Part B. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to a TDAP vaccine under Medicare Part B. Therefore, we decided that the Plan does not have to pay for a TDAP vaccine provided on May 4, 2021.
Benefits for a TDAP vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.