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

We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) performed on April 28, 2021.
You asked the Plan to waive the copayment for the EKG. You say that you should not have separate copayments for the same visit. 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 $20 copayment for each non-radiological diagnostic service, including EKG's. You have been asked to pay $14.27, which is less than the $20 copayment for the EKG. An EKG 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 an electrocardiogram (EKG) performed on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80053, 82607, 85025, 85027, 84443)
rendered by the out-of-network (OON) provider on June 9, 2021 and June 18, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the laboratory services (80053, 82607, 85025, 85027, 84443) rendered by the out-
of-network (OON) provider on June 9, 2021 and June 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on January 3, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that that the ambulance
came to your house and treated you with glucose and advised that if you needed to go to the emergency room
(ER), they could take you but that the ER was packed. You say that your blood sugar was under control, and
you did not need to go to the hospital. The Plan denied your request. The Plan says the Medicare ambulance
benefit is a transportation benefit and without transportation there is no payable service.
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 January 3, 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 response and treatment, no transport
(A0998) provided on January 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission with post-stabilization care provided
from July 12, 2021, through July 14, 2021.

You asked the Plan to pay for an inpatient admission with post-stabilization care. The Plan denied your request.
The Plan says that the medical records demonstrate the enrollee's emergency medical condition had stabilized
by 10:01 a.m. on July 12, 2021 such that it met the Medicare standard for transferability, namely that within
reasonable medical probability no material deterioration of her condition was likely to result from or occur
during transfer had the enrollee been transferred to a Plan facility on July 12, 2021.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.

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 an inpatient admission with post-stabilization care. Our reviewer says that the post stabilization care services were not medically necessary or
reasonable. Our physician reviewer found that as of 10:01 a.m. on July 12, 2021 the enrollee was
hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility. The post
stabilization care services after 10:01 am on July 12, 2021 at the non-Plan facility were not medically necessary
or reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that
the enrollee was not stable for transfer on any dates of service.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an inpatient admission with post-stabilization care have not been met.
Therefore, we decided that the Plan does not have to pay for an inpatient admission with post-stabilization care
provided from July 12, 2021, through July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on November 11, 2020 and June 5, 2021.
You asked the Plan to pay for the dental services. You say that you saved yourself a lot of money but having services done out of the country. You say that you had to borrow money to get these services done and you can't afford to pay the cost in the United States. The Plan denied your request. The Plan says routine dental services received while out of the country are not a Medicare covered benefit and excluded from coverage under your Plan.
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, dental services provided by a facility other than your contract dentist are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on November 11, 2020 and June 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist services, an EKG and an ultrasound of the heart provided on May 14, 2021, and June 11, 2021.
You asked the Plan to waive the copayments for specialist services, an EKG and an ultrasound of the heart. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 services. Your contract with the Plan also clearly says that you must pay a $30 copayment for non-radiological diagnostic services, and a $130 copayment for ultrasounds. You received specialist services on May 14, 2021. Therefore, you are responsible to pay the $45 copayment. You received an EKG on May 14, 2021. Therefore, you are responsible to pay the allowed amount of $16.88, which is less than the $30 copayment. You received an ultrasound of the heart on June 11, 2021. Therefore, you are responsible to pay the $130 copayment. The total amount you owe is: $191.88. You have been asked to pay the total amount of $191.88 for specialist services, an EKG and an ultrasound of the heart. Specialist services fall within the physician/practitioner services, including doctor's office visits benefit category. An EKG and an ultrasound of the heart fall 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 copayments for specialist services, an EKG and an ultrasound of the heart provided on May 14, 2021, and June 11, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection control supplies coded S8301 provided on June 28, 2021.
You asked the Plan to pay for the Iv tubing extension set and the infection control supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes S1015 and S8301 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the Iv tubing extension set and the infection control supplies have
not been met. Therefore, we decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection control supplies coded S8301 provided on June 28, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was diagnosed with pneumonia in the Emergency Department on 12/16/21 and discharged home. She has
ongoing weakness. There is no documentation of any worsening of respiratory status. Medical problems are
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in
and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for myocardial perfusion imaging, a stress
tests and does not have to waive the coinsurance for medical supplies provided on June 25, 2021.

You asked the Plan to waive the copayments for myocardial perfusion imaging, a stress tests and to waive the
coinsurance for medical supplies. You say that you disagree with the charges. The Plan denied your request.
The Plan says the claims were processed correctly and you are being charged the correct 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 $130
copayment for radiological diagnostic services, a $30 copayment for non-radiological diagnostic services, and
20% coinsurance for medical supplies.

You received myocardial perfusion imaging on June 25, 2021. Therefore, you are responsible to pay the $130
copayment.

You received a stress test on June 25, 2021. Therefore, you are responsible to pay the $30 copayment.

You received medical services on June 25, 2021. The total allowed amount is $500 and 20% of that is $100.

The total amount you owe is: $260.

You have been asked to pay the total amount of $260 for myocardial perfusion imaging, a stress tests and
medical supplies. Myocardial perfusion imaging, a stress tests and medical supplies fall 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
copayments for myocardial perfusion imaging, a stress tests and does not have to waive the coinsurance for
medical supplies provided on June 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care at diagnosis related group (DRG) 853
provided from April 14, 2020, to April 16, 2020.
You asked the Plan to pay for inpatient care. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this DRG is correct, because the primary
diagnosis code of A41.9 is not supported so DRG 623 is supported instead.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with A41.9 - Sepsis, Unspecified Organism. 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 inpatient care. Our reviewer says that the documentation
does not support the requested DRG for this stay. Our physician reviewer found the enrollee was diagnosed
with an open wound and methicillin-resistant staphylococcus aureus (MRSA) prior to the hospital stay.
Although sepsis is documented in the hospital documentation, documentation does not clearly support this
unspecified sepsis as a primary diagnosis. Vital signs were elevated while in emergency room, however
remained within normal limits throughout hospitalization. Subsequent hospital care visits documents sepsis
with no supporting documentation. Documentation does not support tissue or organ damage due to sepsis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital care at diagnosis related group (DRG) 853 provided from April 14, 2020, to April 16,
2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is necessary to be able to independently care for yourself. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee does not meet all the required Medicare criteria for admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
cervicothoracic spinal surgery for kyphosis. Medical problems are stable. There are no complex nursing or
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a non-emergent ambulance transport
(A0425) received on July 19, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you had no way of getting
from the hospital to the rehab without an ambulance. The Plan denied your request. The Plan says the cost-
sharing was applied correctly. The Plan says a review of trip notes from the ambulance service were reviewed
and considered in the decision.
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 Ambulance Services.
You have been asked to pay a $256.08 copayment for an ambulance transport, which fall within the Ambulance
Services benefit category. The contractually required copayment for each Medicare-covered ambulance service
is $350. Since the amount you have been asked to pay is less than the required copayment, you are only
responsible for the lesser 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 a non-emergent
ambulance transport (A0425) received on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral evaluation (D0120) provided on August 2, 2021.
You asked the Plan to reimburse you for the dental service. You say that it was your understanding that your policy covered 1 dental visit every 12 months. You say that it has been well over 12 months since your last exam and cleaning. You say that you have been reimbursed for services from this provider in the past. You also say that you were not informed by the dentist or your plan that the services would not be covered. The Plan denied your request. The Plan says you were not enrolled in the dental plan on the date of service in this case. The Plan also says that you were mailed an Annual Notice of Change (ANOC) showing the changes with your plan from 2020 with dental benefits to 2021 without dental benefits.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the oral evaluation (D0120) provided on August 2, 2021.