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

 We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on December 14, 2020.  You asked the Plan to pay for the ambulance services. You say that the enrollee was not capable of reliably reporting her experiences or how she was doing or feeling. You also say that neither you nor the receiving facility were informed of the decision on form of transportation or able to make different arrangements. The Plan denied your request. The Plan says the provided documentation does not support the medical necessity of the services provided.   The Plan says that there was no documentation of why the enrollee was unable to be transported by wheelchair, if enrollee was bed confined, unable to stand without assistance, or unable to sit in a wheelchair. The Plan also says that the enrollee also had alternative transportation options.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Specifically, there was no documentation submitted to show the medical necessity of the ambulance transport. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 29, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that you should not have extra bills once you pay your copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for specialist office visits.   You have been asked to pay a $45 copayment for the specialist office visit. Specialist office visits fall within the Physician/Practitioner Services Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on November 24, 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 services are not covered.  The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient.     We looked at the file and Medicare rules. Billed procedure codes 88141 and 85060 have a PC/TC indicator of 8. The file shows that the services were rendered in the hospital outpatient setting. Payment is included in payment to the facility. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the endodontic therapy, anterior tooth (excluding final restoration) (D3310), core buildup, including any pins when required (D2950), resin-based composite - two surfaces, anterior (D2331), and crown - porcelain/ceramic (D2740) provided April 27, 2021.  You asked the Plan to provide additional payment for the root canal, core buildup, resin-based composite and crown. You say that you believe the dentist's office may not have used the proper codes to submit the claims. The Plan denied your request. The Plan says the root canal and filling have been covered with 50% coinsurance and the remaining services are not covered under your 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. The Plan covers root canals and fillings with 50% coinsurance.  We looked at the file and Medicare rules. The Plan provided documentation showing that the root canal and filling were covered with 50% coinsurance. Though the Plan offers a dental benefit in excess of Medicare coverage, the crown and core buildup are not among those covered under this benefit. Therefore, we decided that the Plan does not have to provide additional payment for the endodontic therapy, anterior tooth (excluding final restoration) (D3310), core buildup, including any pins when required (D2950), resin-based composite - two surfaces, anterior (D2331), and crown - porcelain/ceramic (D2740) provided April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for acute care hospital services provided to the enrollee on August 25, 2021.  You asked the Plan to pay for the services. You say that the enrollee presented to Internal Medicine complaining of bleeding from gums after teeth extracted. The Plan denied your request. The Plan says the services were not urgent or 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 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 acute care hospital services provided to the enrollee on August 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a Tangential biopsy of the skin (11102) provided on August 6, 2021.  You asked the Plan to waive the copayment for the biopsy. You say that the services should be covered because all you had done was the biopsy and no anesthesia was used. The Plan denied your request. The Plan says the cost sharing applied correctly based on the services rendered.  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 $350 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.     You have been asked to pay a $218.77 copayment for a biopsy of the skin, which is less than the $350 stated in the Plan's contract. The records indicate that this surgical service was provided in an outpatient setting.  Biopsy's fall within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayment for a Tangential biopsy of the skin (11102) provided on August 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the SNF care provided from March 31, 2021, to April 10, 2021, and April 18, 2021, to April 29, 2021.  You asked the Plan to pay for the SNF care provided from March 31, 2021, to April 10, 2021, and April 18, 2021, to April 29, 2021. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive nursing services during the time frames which would be considered skilled services by Medicare.  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 pay for the SNF care provided from March 31, 2021, to April 10, 2021, and April 18, 2021, to April 29, 2021. Our reviewer says the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care provided from March 31, 2021, to April 10, 2021, and April 18, 2021, to April 29, 2021. have not been met. Specifically, the file does not indicate that the enrollee received skilled services on the dates of service in question. Therefore, we decided that the Plan does not have to pay for the SNF care provided from March 31, 2021, to April 10, 2021, and April 18, 2021, to April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for SelectMDx testing (81479) provided on June 24, 2021.  You asked the Plan to pay for SelectMDx testing. You say that this is recommended by treatment guidelines. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.  The Plan must follow Medicare rules. Medicare rules say that code 81479 is not considered medically necessary when used for SelectMDx.  We looked at the file and Medicare rules. The testing at issue is not considered medically necessary. Based on this information, we decided that Medicare rules for coverage of SelectMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for SelectMDx testing (81479) provided on June 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 14, 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 procedure code 80307 has not met the associated frequency relationship criteria.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found confirmation drug testing for multiple drug classes was performed. In this case, the confirmation definitive drug testing is not supported and will be considered not medically reasonable and necessary. There was no provided abnormal or unexpected urine drug screening prior to consideration of the broader panel tested, and there was no report of suggestive evidence of noncompliance with prescriptions. Also, there is no support made in the documentation for frequent drug testing.  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 pay for drug testing services provided to the enrollee on April 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on August 18, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you were not given any medication orally. You say that no one discussed with you what medications would be given to you intravenously. You also say that when you woke up after surgery, no one offered or administered any drugs to you orally. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare 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 pay for the self-administered drugs provided in an outpatient setting on August 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from July 30, 2021, to August 3, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should not have to pay this copayment because you only had a room for one of the days you were in the hospital.  You stated that due to a room shortage, you had to stay in the hallway surrounded by a curtain. 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 $325 copayment per day for days 1-5 for inpatient hospital care.    Records show that you were in the hospital for four days.  You were charged a $325 copayment per day, for a total of $1300.  This copayment applies regardless of whether or not you are in a room or elsewhere in the hospital. 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 inpatient hospital services you received from July 30, 2021, to August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99203) Electrical stimulation (G0283) provided August 3, 2021.  You asked the Plan to pay for the chiropractic services. You say that your benefits allow for the chiropractic services that you received. You had this done because a pain in your back made waling any distance extremely difficult. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) Electrical stimulation (G0283) provided August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for prolotherapy, a transcutaneous electrical nerve stimulation device (TENS), and a pneumatic device provided to the enrollee on March 30, 2021.  You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the services provided were not readily consistent with the generally accepted standards of practice/care for the management of neuropathy/neuropathic pain. The vitamin/nutrient injections administered have not been shown in well designed studies to have any meaningful impact on patient care and/or outcomes.  Nor have they been shown to result in superior outcomes compared to standard pharmacotherapy. In as much these services would not have been medically necessary, as defined by Medicare.  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 pay for prolotherapy, a transcutaneous electrical nerve stimulation device (TENS), and a pneumatic device provided to the enrollee on March 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you received on January 26, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that this service was related to COVID-19, so the copayment should be waived. 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 $285 copayment for ambulance services.     You have been asked to pay a $285 copayment for the ambulance services. There is no provision in your contract for a waiver of this copayment for any reason. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services you received on January 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from August 1, 2021, to August 4, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $300 per day for days 1-7 and $0 per day for days 8-90 for each inpatient admission.   The record shows you were in the hospital from August 1, 2021, to August 4, 2021, but there is no copayment for the discharge date. Therefore, you have been asked to pay $300 per day for the first three days of inpatient hospital services.  The total for your stay is $900 ($300 copayment x 3 days = $900). Inpatient hospital services fall within the Inpatient Hospital Care 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 copayment for inpatient hospital services provided from August 1, 2021, to August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a crown (D2740) provided by an out-of-network provider on June 24, 2021  You asked the Plan to pay for a crown. You say that you called and verified you had covered for these services. The Plan denied your request. The Plan says the enrollee is responsible for 100% of the cost for out-of-network services.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.     We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown have been met. The correct amount has been charged. The rendering dentist is out-of-network. Enrollees are responsible for 100% of out-of-network services. Therefore, we decided that the Plan does not have to pay for a crown (D2740) provided by an out-of-network provider on June 24, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for services you received with an out-of-network primary care doctor on September 15, 2021.  You asked the Plan to waive the coinsurance for the out-of-network primary care services. You say that you had an appointment with another doctor in the office, but they kept pushing the appointment out.  You stated that you asked if you could see another doctor in the office and whether or not the other doctor accepted your insurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 50% coinsurance for out-of-network primary care.  You have been asked to pay 50% coinsurance for the out-of-network primary care services. This coinsurance applies regardless of the reason you saw this out-of-network provider. 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 services you received with an out-of-network primary care doctor on September 15, 2021.