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

We decided that the Plan does not have to pay for the ambulance transportation services provided on February 2, 2021.
You asked the Plan to pay for the services provided. You say that the modifier is considered a payable code. The Plan denied your request. The Plan says the claim was not billed according to guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of code A0429 is Ambulance service, basic life support, emergency transport. The code was billed with a -QL modifier. We find that CPT code A0429-QL is not supported by the medical records. In this case, the records show the enrollee had rigor. No cardiopulmonary resuscitation (CPR) was attempted due to obvious death. The records provided do not indicate the enrollee died after the ambulance was called, but before it arrived. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation services provided on February 2, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on June 30, 2021.
You asked the Plan to pay for the occlusal guard. You say that you feel this service was billed incorrectly and it should be covered. You say you need this guard for temporomandibular jaw dysfunction because you grind your teeth. The Plan denied your request. The Plan says this service is not covered under your dental benefit. The Plan is required to process services as submitted by the provider; however, the requested alternative code is also not covered by the dental benefit.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard (D9944) provided on June 30, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on June 28, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you don't think you should have to pay this copayment because the ear, nose and throat doctor didn't show up for a consult. You said that they didn't do anything for 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 $90 copayment for emergency room visits.
You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the extent of services you receive at the ER. 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 emergency room (ER) visit you had on June 28, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) after November 24, 2021.
You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care continues to be medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for SNF care are no longer met.
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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 90-year-old male with arthritis, chronic obstructive pulmonary disease, atrial fibrillation and hypertension. In this case, there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) after November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided on April 5, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON nursing facility visit. You say that the provider relies on the facility to get authorization. The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."]
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 did not pre-approve the item/service at issue. It is the provider's obligation to confirm the patient's insurance coverage prior to rendering services. 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 nursing facility visit provided on April 5, 2021, by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcatheter services provided on April 6, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says the services were not billed as required by coding guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 99153 is a technical component only code. This code is covered only as a diagnostic test and therefore does not have a related professional code. Based on this information, we decided that Medicare rules for coverage have not been met.
We find that CPT code 37214 was billed with code 37184. CPT code 37214 may be eligible for payment when billed with this code pair. The claim provided does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the transcatheter services provided on April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (code D0180) you received on July 13, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you verified your dental coverage and confirmed that the dentist was in-network before you saw him. The Plan denied your request. The Plan says this particular service is not covered under your dental benefit.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (code D0180) you received on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for foot ulcer debridement and skin graft services you received at an outpatient hospital facility from March 4, 2021, to April 8, 2021.
You asked the Plan to waive the copayments for the debridement and skin graft services. You say that it was not communicated to you that each individual service would have a $250 copayment. You said that you were told there would be a one-time $250 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 $250 copayment for surgery or other services at an outpatient hospital facility. You have been asked to pay a $250 copayment for the debridement and skin graft services. The debridement
and skin graft services fall within the surgery or other services at an outpatient hospital facility benefit category. This is a per service/per date of service copayment obligation. 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 foot ulcer debridement and skin graft services you received at an outpatient hospital facility from March 4, 2021, to April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for gym services provided in February 2021 and
March 2021.
You asked the Plan to reimburse you for gym services. The Plan denied your request. The Plan says you do not have a Fitness benefit under your plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits. Therefore, we decided that the Plan does not have to reimburse you for gym services provided in February 2021 and March 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on September 25, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON psychotherapy services. You say that these services were medically necessary and the provider shouldn't be punished for the hospital's failure to get authorization. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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 did not pre-approve the item/service at issue. It is the provider's obligation to confirm insurance coverage prior to rendering services. 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 psychotherapy services provided on September 25, 2020 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care visit you had on June 22, 2021.
You asked the Plan to waive the copayment for the primary care visit. You say that your Medicare and Veteran's Affairs (VA) insurance should be primary, and you should not have any copayments. The Plan denied your request. The Plan says you are not enrolled in Original Medicare- you are enrolled with the Plan, which is a Medicare replacement plan. The Plan is your primary insurer for services that you receive outside of a VA facility. The Plan says that 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 $15 copayment for primary care visits. You have been asked to pay a $15 copayment for the primary care visit. 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 primary care visit you had on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on December 21, 2020.
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 must 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 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 out of network physician services provided to the enrollee on December 21, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the suction-assisted lipectomy service you received on February 9, 2021.
You asked the Plan to pay for the suction-assisted lipectomy service. You say that you previously used this provider before you were on Medicare and it was covered. You said that you have confidence in him and his experience with your health. The Plan denied your request. The Plan says this service is not covered because 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 a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the suction-assisted lipectomy service you received on February 9, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on March 1, 2021, to April 5, 2021. You are an out-of-network (OON) provider.
You asked the Plan to pay for the OON chiropractic services. You did not provide an argument in your appeal request, you just provided medical records. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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. You are 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 chiropractic services provided on March 1, 2021, to April 5, 2021. You are an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the placement of a breast localization device (19281) rendered on June 23, 2021.
You asked the Plan to waive the copayment for the placement of a breast localization device. You say that there was no surgery. You also say they were unable to find the spot where they were to do the surgery. You also say you sat on a machine for one and a half hours waiting to see what was up. The Plan denied your request. The Plan says you were 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 $100 copayment for outpatient surgery or procedure at an outpatient hospital facility or ambulatory surgical center.
You have been asked to pay a $100 copayment for the placement of a breast localization device. The placement
of a breast localization device falls within the Outpatient Hospital Services benefit category. The record shows
that this procedure was discontinued after the beginning of the procedure and after the administration of
anesthesia. 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 placement of a breast localization device
(19281) rendered on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventative procedure (D1999), porcelain/ceramic crown (D2740) and core buildup (D2950) provided on July 7, 2021.
You asked the Plan to pay for the dental services. You say that you disenrolled in the optional benefits because you were previously told that you were not covered for care with your preferred dentist. After you disenrolled, the Plan approved payment for previous services, and you feel this care should be covered as though you were still enrolled in the optional benefits because you only disenrolled due to misinformation. The Plan denied your request. The Plan says these services are not covered by your dental benefit on the date in question.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified preventative procedure (D1999), porcelain/ceramic crown (D2740) and core buildup (D2950) provided on July 7, 2021.
Your complaint about potential misinformation or a change in how a claim was processed affecting your coverage choices 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 pay for out of network physician services provided to the enrollee on February 23, 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 must 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 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 out of network physician services provided to the enrollee on February 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for inpatient hospital services you received from June 19, 2021, to June 22, 2021.
You asked the Plan to waive the cost sharing for the inpatient hospital services. You say that it was your understanding that all COVID-19-related expenses were to be covered in full. The Plan denied your request. The Plan says you were charged these cost sharing amounts correctly. You had not yet met your deductible prior to these services. The Plan says that there was no cost share waiver for inpatient hospital services due to COVID-19 in place 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 10% coinsurance for inpatient hospital care after your $245 annual deductible is met.
You have been asked to pay the remaining amount on your deductible, and then 10% coinsurance for the inpatient hospital 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 cost sharing for inpatient hospital services you received from June 19, 2021, to June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assisted living facility visit provided on May 21, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON assisted living facility visit. You say that the assisted living facility was responsible for getting authorization for these services. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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 did not pre-approve the item/service at issue. It is the provider's obligation to confirm the patient's insurance information prior to rendering services. 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 assisted living facility visit provided on May 21, 2021, by an out-of-network (OON) provider