Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your 
request. The Plan says your benefit does not cover more than 40 one-way trips per year. 
 
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 up to 40 one-way trips to Plan-approved locations every year. 
 
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. Therefore, we decided that the 
Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Prometheus IBD Monitr testing provided on January 12, 2021.

You asked the Plan to pay for the Prometheus IBD Monitr testing. You say that this testing is able to measure mucosal healing in Crohn's disease patients. This information can be used to assess treatment response and severity of disease. The Plan denied your request. The Plan says this testing was denied due to billing and coding reasons.

The Plan must follow Medicare rules. Medicare rules say that MDT services, such as the Prometheus IBD Monitor assay, are covered when they are approved by the MolDX contractor and assigned a unique identifier. 

We looked at the file and Medicare rules. We reviewed the DEX Diagnostic Exchange database which publishes tests reviewed through the MolDX process. The test at issue is not listed in this database meaning that it has not been reviewed. Tests are covered only when they have been reviewed and approved by the MolDX contractor. Based on this information, we decided that Medicare rules for coverage of the Prometheus IBD Monitr testing have not been met. Therefore, we decided that the Plan does not have to pay for the Prometheus IBD Monitr testing provided on January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services provided on May 10, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the surgical pathology services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 surgical pathology services provided on May 10, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles immunization provided on May 14, 2021. 
 
You asked the Plan to pay for immunization. You say that you had no knowledge that this was not covered and 
had you known; you would not have gotten it. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because this vaccine is not covered through Medicare Part B and should be 
covered under your Medicare Part D benefits instead. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to immunization. 
Therefore, we decided that the Plan does not have to pay for a shingles immunization provided on May 14, 
2021.  
 
Benefits for immunization 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: Favorable

We decided that the Plan has to hold you harmless for the home visit (99348) provided on April 26, 2021. 
 
You asked the Plan to hold you harmless for the home visit. You say that you would like reconsideration 
because only a $20 copayment should be applied to this service. The Plan denied your request. The Plan says 
that the diagnosis on this claim is not covered because it is excluded by the plan. 
 
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 referred for the home visit by a contract provider. The file does not show that the Plan provided 
notice that the home visit would not be covered. Under Medicare rules, this means the home visit is considered 
approved by the Plan. Of note, these services were rendered by your in-network primary care physician. The 
Plan has not forwarded any medical records to show that a dental service was rendered. There is no verification 
from the Plan that the services rendered were not medical in nature. Therefore, we decided that the Plan has to 
hold you harmless for the home visit (99348) provided on April 26, 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 the outpatient office visit (99213) provided on March 24, 2021 to March 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that the primary care physician was on medical leave and so this provider was seeing her patients during this time. 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. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 outpatient office visit (99213) provided on March 24, 2021 to March 26, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 29, 2021.

You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. 

Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129, L36362, and L36523 to support their denial. However, LCD L36139, L36129, L36362, and L36523 are not valid for the provider's billing state of Florida. Therefore, we are unable to use LCD L36139, L36129, L36362, and L36523 to substantiate our decision. 

While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the care needed can be had at home with home health care or at an alternative level 
of care within the nursing home. 

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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
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 skilled nursing facility 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.

You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says only two more visits can be approved to teach stretching and home exercises.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been authorized additional therapy to be instructed in a home exercise program. The requested services are not part of a maintenance program.

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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for remote evaluation of an implantable pacemaker and defibrillator provided on April 29, 2021.

You asked the Plan to waive the copayment for diagnostic service. You say that this same service is provided to you every 6 months and this processing does not appear correct. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $30 copayment for diagnostic service. 

You have been asked to pay $30 copayment for diagnostic service. Diagnostic service falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 remote evaluation of an implantable pacemaker and defibrillator provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee out of network on January 19, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The 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 physician services provided to the enrollee out of network on January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) provided April 20,
2021.

You asked the Plan to pay for the complete upper denture. You say that your first dentures were faulty, and you
didn't get a chance to have them fixed. The Plan denied your request. The Plan says you have exceeded the
frequency limit for this 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. The Plan covers the complete
upper denture once every five plan years.

We looked at the file and Medicare rules. The Plan provided documentation showing that a complete upper
denture was previously covered on October 2, 2020. Based on this information, we decided that the Plan's
frequency limit for coverage of the complete upper denture has been exceeded. Therefore, we decided that the
Plan does not have to pay for the complete denture - maxillary (D5110) provided April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with an orthopedist on June 2, 2021.

You asked the Plan to waive the copayment for the orthopedist visit. You say that you had to wait almost two hours to be seen and you said that they did not discuss surgery aftercare with you. 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 $45 copayment for specialist visits. 

You have been asked to pay a $45 copayment for the orthopedist visit. This copayment applies regardless of the extent of services you receive. 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 the office visit you had with an orthopedist on June 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay provided 
January 22, 2021, to February 9, 2021. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that you were told 
there would be no copayment for the services. The Plan denied your request. The Plan says the copayment was 
applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment per day, days 1 to 7 for inpatient hospital care.  

You have been asked to pay a total of $1,750 ($250 copayment x 7 days = $1,750) for the inpatient 
rehabilitation services. This inpatient stay falls 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 the inpatient rehabilitation stay provided January 22, 2021, to 
February 9, 2021.  
 
Your complaint about potentially being provided misinformation is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with your cardiologist on April 28, 2021.

You asked the Plan to waive the copayment for the telehealth visit. You say that you were never advised that the Plan stopped waiving copayments for these telehealth services. The Plan denied your request. The Plan says it has waived the copayments for the telehealth visits you had on March 11, 2021, to April 14, 2021. The Plan says that you were charged the copayment for date of service April 28, 2021, 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 $30 copayment for telehealth visits with a specialist. 

You have been asked to pay a $30 copayment for the telehealth visit. There is no provision in your contract for a waiver of this amount. 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 the telehealth visit you had with your cardiologist on April 28, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 6, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services represented by code 99153 
provided on April 22, 2021. 
 
You asked the Plan to pay for code 99153. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided 
represent professional charges; however, procedure code 99153 was provided in a facility with a place of 
service code of 22. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical 
Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services represented by code 99153 provided on April 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the myocardial perfusion imaging and the transthoracic echocardiography (TTE) you received on May 21, 2021.

You asked the Plan to waive the copayments for the myocardial perfusion imaging and the TTE. You say that you do not believe there was a need for two tests, so you should only have one 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 $235 copayment for diagnostic radiology services provided in an outpatient hospital facility.

You have been asked to pay a $235 copayment for both the myocardial perfusion imaging and the TTE. These are two separate and distinct tests. These copayments apply regardless of the reason for the tests. 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 myocardial perfusion imaging and the transthoracic echocardiography (TTE) you received on May 21, 2021.