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

 We decided that the Plan does not have to pay for ambulance services received on May 30, 2021.  

You asked the Plan to pay for the services. You say that the enrollee declined a trip to the hospital. The Plan denied your request. The Plan says this is not covered under any normal circumstances.  

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 30, 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 services received on May 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), fluoride application (D1208), and filling (D2331) provided from July 28, 2021, to September 9, 2021.

You asked the Plan to pay for the dental services. You say that you were not made aware that the provider you saw was out of network. You also say that you always go to the same provider. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services received out of network are paid based on the allowed amount. The Plan says that out of network dentists may bill you for any amount greater than what the plan pays. The Plan also says that filling is not listed as a covered service.

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 and the oral exam, prophylaxis, and fluoride application are listed as covered, out of network dentists may bill you for any amount greater than what the plan pays the provider. Additionally, the filling is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), fluoride application (D1208), and filling (D2331) provided from July 28, 2021, to September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat lift motor (A9270) provided on August 6, 2021 by an
out-of-network (OON) provider.
You asked the Plan to pay for the motor. You say that you were told by the supplier that the lift chair motor
was a covered but the chair is not. The Plan denied your request. The Plan says enrollee's must receive their
medical services from an in-network provider with the exception being urgent or emergent services. Nonemergent
services with non-contracted providers require prior authorization before services being rendered.
Records necessary to determine medical necessity have not been provided.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
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 seat lift motor
(A9270) provided on August 6, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for the services provided to you on September 2, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says that these services are not covered.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.  You were provided the services by a contract provider. The file does not show that the Plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the services provided to you on September 2, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for immunization services provided to the enrollee on September 23, 2020.
You asked the Plan to pay for the services. You say that the enrollee went to the office for a checkup and two vaccines. The Plan denied your request. The Plan says the enrollee is not enrolled in this portion of the benefit package.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the orthoses provided on March 8, 2021.  

You asked the Plan to pay for the DME. The Plan denied your request. The Plan says the documentation submitted did not sufficiently support the billed supply code.  

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.  

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the documentation submitted does not support that the member's physician ever discussed the need for the billed orthoses. Additionally, there is no indication in the medical records that the member has a condition for which the billed orthoses would be appropriate. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the orthoses provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services provided by an opt-out provider on March 3, 2021.  You asked the Plan to pay for dental services. You say that you think that the Plan should pay for this. The Plan denied your request. The Plan says this 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 until April 13, 2022. Therefore, we decided that the Plan does not have to pay for dental services provided by an opt-out provider on March 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the testing services provided on June 22, 2021.  You asked the Plan to pay for the services provided. You say that no other service was rendered. The Plan denied your request. The Plan says the testing does not meet the requirements needed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We looked at the file and the rules. Autonomic function testing, when performed with a device is to be billed with CPT code 95999. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the testing services provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services (92012) provided on October 1,
2021, by an out-of-network (OON) provider.
You asked the Plan to pay for ophthalmological services. You say that the patient was in an office setting at the
time services were rendered and the patient could not choose an in-network optometrist as they do not provide
services in the patient's place of residence. You also say that your provider has no prior knowledge of which
patients he will be required to see, since he receives a list of patients who require optometry care once he
arrives at the facility. The Plan denied your request. The Plan says an authorization was not obtained prior to
the services being rendered and the provider is not participating with the member's plan. The Plan also says that
it was determined that the services were not urgent or emergent in nature.
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 ophthalmological services (92012) provided on
October 1, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 12,
2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your
request. The Plan says Medicare covers lipid panel testing as cardiovascular screening once every 5 years and
denies coverage for all cardiovascular genetic risk assessment panels for patients with suspected or documented
cardiovascular disease.
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 Medicare only covers a lipid panel consisting of a total cholesterol, HDL cholesterol, and triglyceride once every 5 years as cardiovascular screening. The review has determined that the services at issue in this case are not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the crown (D2740) provided on July 28, 2021.
You asked the Plan to pay an additional amount for the dental service. You say that you say that you were advised the crown would be covered at 50% of $1,000, minus the $100 deductible. You also say that now you are being told that your coverage only covers half of $276. The Plan denied your request. The Plan says the claim was processed correctly.
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 and crown is listed as covered, there is a 50% coinsurance of the covered plan allowance after the $100 annual deductible is met. The record shows that the allowed amount for the crown is $452.50. The $100 deductible was applied, leaving a $352.50 allowed amount x 50% coinsurance = $176.25. The provider in this case can also balance bill you as they are not a network provider. Therefore, we decided that the Plan does not have to pay an additional amount for the crown (D2740) provided on July 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (70450) provided August 22, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed and cannot be paid separately.  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 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (70450) provided August 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve progressive lenses.
You asked the Plan to pre-approve progressive lenses. You say that the progressive lenses are medically necessary. The Plan denied your request. The Plan says this lens upgrade is not covered under your benefits.
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. We looked at the file and the Plan's rules. Though the Plan offers vision benefits in excess of Medicare coverage, the progressive lenses are not among those covered service. Based on this information, we decided that the Plan's rules for coverage of progressive lenses have not been met. Therefore, we decided that the Plan does not have to pre-approve progressive lenses.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0365) provided on October 12, 2021.  You asked the Plan to pay for the dental service. You say that your existing crown is over 40 years old. You also say that the roots are abscessed and blocked by calcification. The Plan denied your request. The Plan says cone beam CT capture and interpretation is not listed as a covered service.  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 cone beam CT capture and interpretation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0365) provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series
x-ray (D0210), scaling and root planing (D4341) for the upper left quadrant, and scaling and root planing
(D4342) for the lower left quadrant provided on May 19, 2021 by an out of network provider.

You asked the Plan to pay for the dental services. You say that you were not informed by the dental office or
your plan that this provider was out of network. You say that it is fraudulent to misrepresent this provider as a
plan provider while sending full bills to the patient. You also say that these services should be covered. The
Plan denied your request. The Plan says scaling and root planing are not listed as covered service. The Plan
also says that dental services received out of network 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.

Though the Plan offers a dental benefit in excess of Medicare coverage and the oral evaluation and complete series x-ray are listed as covered, dental services received out of network are not among those covered under this benefit. Additionally, scaling and root planing are not covered regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), scaling and root planing (D4341) for the upper left quadrant, and scaling and root planing (D4342) for the lower left quadrant provided on May 19, 2021 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx test provided to the enrollee on December 27, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this is a non-covered routine screening exam.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found FoundationOneCDx is a qualitative next-generation sequencing based in vitro diagnostic test for advanced cancer patients with solid tumors and is for prescription use only. The review indicates that there was no specific clinical rationale for the obtained laboratory test. The review has determined that the enrollee did not need this 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx test provided to the enrollee on December 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit (99213) and strapping of toes (29550) provided on May 18, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a specialist office visit and strapping of toes. You say that the doctor informed the front desk secretary to obtain prior authorization, yet for some unknown reason, there was a misconception, and the patient was called in for treatment, prior to obtaining authorization. You also say that the doctor rendered medical services assuming that authorization was obtained. The Plan denied your request. The Plan says it was determined that the services were not urgent or emergent in nature. The Plan also says that an authorization was not obtained prior to the services being rendered and the provider is not participating with the member's plan.

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 a specialist office visit (99213) and strapping of toes (29550) provided on May 18, 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 the fees for individual use health club services purchased on
April 1, 2021.

You asked the Plan to pay for the health club fees. You say that this is a legitimate fitness facility, and you
should be reimbursed for these fees. The Plan denied your request. The Plan says that the criteria for
reimbursement of health club services are not met.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

The Plan's rules for coverage of gym benefits have not been met because the facility in this case does not meet
the Plan's definition of a qualified health club. In addition, the fees at issue are day pass fees, which are not the
same as a membership. Therefore, we decided that the Plan does not have to pay for the fees for individual use
health club services purchased on April 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay provided from July 24, 2021, to July 31, 2021.
You asked the Plan to waive the copayment for skilled nursing services. You say that another bill for an unrelated problem was submitted by a separate nursing home and the allotted time seems to have crossed to this bill. The Plan denied your request. The Plan says the cost-share was applied correctly. The Plan also says you are responsible for becoming acquainted with your covered services and rules defined by the EOC.
The Plan explains that from the time you were discharged from the previous SNF to the time you were admitted to the facility for the timeline being appealed, only 37 days had passed. This means the two SNF stays are part of the same benefit period.
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 $0 copayment, each day, for the first 20 days; a $184 copayment, each day, for days 21 through 53; and a $0 copayment for additional covered days, up to 100 days for Skilled Nursing Facility (SNF) Care. You have been asked to pay a $736 copayment for skilled nursing services. The services at issue fall within the Skilled Nursing Facility (SNF) Care benefit category. For the timeline being appealed, you spent a total of 8 days in the SNF. However, the 16 days from the previous facility are also accounted for since it is part of the same benefit period. This means that the first 4 days of service for the dates being appealed are subject to the $0 copayment for days 1 through 20, as outlined in the EOC. The final 4 days of service are days 21 through 24 ($184 copayment  4 days = $736). 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 skilled nursing facility (SNF) stay provided from July 24, 2021, to July 31, 2021.