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

 We decided that the Plan does not have to pay for the COVID-19 testing (U0003) provided on October 17, 2020.  You asked the Plan to pay for the COVID-19 testing. You say that you would like reconsideration because this testing was medically necessary for you to travel. The Plan denied your request. The Plan says this testing is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the COVID-19 testing have not been met. Specifically, there is no evidence that this testing was ordered by a physician with intent to use the results in the management of a specific medical problem. COVID-19 testing for voluntary travel is not a Medicare covered benefit. Therefore, we decided that the Plan does not have to pay for the COVID-19 testing (U0003) provided on October 17, 2020.
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 June 23, 2021, to June 30, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you believe these
hospital services should be covered in full because it was related to COVID-19. The Plan denied your request.
The Plan says you were charged this copayment correctly. The Plan says that with this claim, you hit your out-
of-pocket maximum. As a result, you are only being charged $1394.77 instead of the full copayment. The
Plan also says that there was no copayment waiver in effect at the time of these services.
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 $250
copayment per day for days 1-7, and a $0 copayment for additional days for inpatient hospital care.
Records show that you were in the hospital for seven days. You were charged a copayment of $250 per day for
seven days, for a total of $1750. However, since you hit your out-of-pocket maximum with this claim, you are
only being charged the remaining $1394.77 of your maximum out-of-pocket amount.
Your Plan has also confirmed that all cost sharing waivers related to COVID-19 treatment ended on May 31,
2021, which is prior to these services. 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 June 23, 2021, to June 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 home, skilled nursing visits.
You asked the Plan to pre-approve the skilled nursing visits. You say that the enrollee has a catheter that needs
to be changed on a regular basis per doctors. The Plan denied your request. The Plan says the records provided
do not support medical necessity of the skilled nursing visits.
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 the skilled nursing visits. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found in this case, the documentation doesn't support that the enrollee requires additional
skilled nursing services or skilled to provide treatment that is medically necessary. The enrollee does not
require additional skilled nursing services to effectively provide treatment, care, and/or services in order to
improve the enrollee's condition, perform a maintenance program to maintain the member's condition and/or
prevent deterioration. The enrollee has been medically stable without any recent exacerbation of chronic
medical problems or hospitalizations. The requested home health services 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 the skilled nursing visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve 2 home, skilled nursing visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound (76700) provided on July 14, 2021.
You asked the Plan to pay for the abdominal ultrasound. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says CPT code 76700 is included in code 93976.
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 76700
is a column II code to column I code 93976. 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 the abdominal ultrasound (76700) provided on July 14,2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial observation care (99220) provided July 23, 2020.
You asked the Plan to pay for initial observation care. You say that please reprocess the claim for payment
based on the extensions in place for COVID-19. The Plan denied your request. The Plan says the claim was
received past the timely filing limitation.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for initial observation care was not filed until September 2, 2021. This means
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for initial observation care (99220) provided July 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from December 10, 2021, forward.

You asked the Plan to pre-approve SNF care. You say that the enrollee could have two (2) more weeks so that they can have the time they need to get on their feet and be able to do all the things the enrollee could do before they broke their hip. The Plan denied your request. The Plan says the stay is not medically necessary.

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 there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from December 10, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210), panoramic x-ray (D0330), and case presentation, detailed and extensive treatment planning (D9450) provided from August 11, 2021, to August 12, 2021.

You asked the Plan to pay for the dental services. You say that your plan covers 2 cleanings and x-ray 2 time per year. You say that you cannot afford this bill. You also say that you feel this dentist is pushing dental work on elderly people that cannot afford it. The Plan denied your request. The Plan says complete series x-ray is not listed as a covered service. The Plan says panoramic x-ray is not listed as covered service.

The Plan says case presentation is not listed as a covered service either. The Plan also says you did not contact them prior to the date of service to verify benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the complete series x-ray, panoramic x-ray, and case presentation are not among those covered under this benefit. Additionally, the record shows that the cleaning was paid for by the Plan. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210), panoramic x-ray (D0330), and case presentation, detailed and extensive treatment planning (D9450) provided from August 11, 2021, to August 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the testosterone undecanoate injection and
therapeutic prophylactic injection provided on November 11, 2020.
You asked the Plan to waive the coinsurance for the testosterone undecanoate injection and therapeutic
prophylactic injection. You say that the provider is erroneously billing an additional $237.71 for this treatment.
You say that you have never had to pay the above copayment and the charges should be removed. The Plan
denied your request. The Plan says the coinsurance 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 20% of
the total cost for other Medicare-covered Part B drugs and administration.
You have been asked to pay a total of $234.58 for the testosterone undecanoate injection and therapeutic
prophylactic injection.
Service Allowed Amount Coinsurance Member Liability
Testosterone Undecanoate Injection $1,157.25 20% $231.45
Therapeutic Prophylactic Injection $15.65 20% $3.13
TOTAL: $234.58
The testosterone undecanoate injection and therapeutic prophylactic injection fall within the "Medicare Part B
prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the testosterone
undecanoate injection and therapeutic prophylactic injection provided on November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0242U) provided May 27, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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 find that CPT code 0242U is not supported in the medical record. Specifically, the place of service listed on the claim (81, laboratory) does not match the place of service listed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (0242U) provided May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on
September 3, 2020.
You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded
as E0675 to treat peripheral arterial disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, these items are not a covered benefit of Medicare or the
Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to
pay for pneumatic compression devices (E0675, E0673) provided on September 3,2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency mileage provided from March 7, 2021, to
March 28, 2021.
You asked the Plan to pay for the transportation services. You say that you wanted to be able to get your
coronavirus vaccine at the same time as the rest of your household. You say you were initially signed up at a
plan facility. You say you cancelled the appointment sine the rest of your household was not able to receive the
vaccine there. You also say that you should be reimbursed at the rate of $.35 per mile for 193 miles for 2 trips
made to the vaccination site where your household was able to get vaccinated at the same time. The Plan
denied your request. The Plan says while a transportation benefit is available, it was not used. The Plan also
says that non-emergency transportation is covered to and from a network provider.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation when 6 round trips.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Specifically, the file does not
indicate that you went to a network provider to receive services. Therefore, we decided that the Plan does not
have to pay for the non-emergency mileage provided from March 7, 2021, to March 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.  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 there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on May 27, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.
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 that the enrollee is a 34-year-old female. A diagnosis of supervision of normal pregnancy, 1st trimester was documented. Genetic testing (Panorama Prenatal Panel Plus) was requested. Based on the age of the
enrollee and other details provided in the documentation, there was no direct clinical indication for this testing. Genetic testing would not likely lead to a change in outcome of the enrollee or fetus.. Therefore, it is considered 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the oncology telehealth visits you had on March 3, 2021, and May 27, 2021.

You asked the Plan to waive the copayments for the oncology telehealth visits. You say that you only speak with the nurse practitioner, not the doctor, so there should be no copayment. The Plan denied your request. The Plan says you were charged these copayments 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 $40 copayment per visit for physician/practitioner specialist services (including telehealth).

You have been asked to pay a $40 copayment per visit for the oncology telehealth visits. These copayments apply to both physician and practitioner services. 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 copayments for the oncology telehealth visits you had on March 3, 2021, and May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on July 28,
2021.
You asked the Plan to pay for the dental service. You say that it has been 3 years since you last received this
service. The Plan denied your request. The Plan says 1 complete series x-ray is covered every 3 plan years. The
Plan also says that the frequency limit has been exceeded.
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 service is listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid for a complete series x-ray that you
received on August 2, 2019. Therefore, we decided that the Plan does not have to pay for the complete series x-
ray (D0210) provided on July 28, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on January 28, 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 testing services provided on January 28, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture.
You asked the Plan to pre-approve acupuncture. You say that you should be eligible for coverage of 20 acupuncture visits. The Plan denied your request. The Plan says acupuncture is not covered for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.
We looked at the file and Medicare rules. The records show that the acupuncture being requested is for treatment of fibromyalgia. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the requested acupuncture is not for treatment of CLBP. Therefore, we decided that the Plan does not have to pre-approve acupuncture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wheelchair ramp, raised toilet seat, and toilet rails provided
on April 6, 2021, and May 8, 2021.

You asked the Plan to pay for a wheelchair ramp, raised toilet seat, and toilet rails. You say that the items at
issue are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment
have not been met.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. Medicare rules state that neither raised toilet seats nor grab bars are covered because they are
not primarily medical in nature.

The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for a wheelchair ramp, raised toilet seat, and toilet rails provided on
April 6, 2021, and May 8, 2021.