Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network 
(OON) provider on June 3, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on June 3, 
2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on
September 17, 2021.
You asked the Plan to waive the copayment for an emergency room visit. You say that your temperature and
vitals were taken at the emergency room. You also say that you sat back in the waiting room for four hours and
then left. 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 $65
copayment for each emergency room visit.
The records show that you were seen at the emergency room on September 17, 2021. You have been asked to
pay a $65 copayment for an emergency room visit. An emergency room visit falls within the Emergency 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 an emergency room visit provided on September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (0012M) rendered by the out-of-network (OON) provider on September 9, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (0012M) rendered by the out-of-network (OON) provider on September 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on April 24, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that when the paramedics arrived, they were able 
to treat you. You say that you were not transported to the hospital even though the situation was serious. You 
also say that you should not be responsible for this bill. The Plan denied your request. The Plan says since no 
transport was provided, 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 April 24, 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 the ambulance response and treatment, no 
transport, (A0998) provided on April 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital clinic visit provided on October 13, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient hospital clinic visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the outpatient hospital clinic visit provided on October 13, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation of the genicular nerves 
(64624). 
 
You asked the Plan to pre-approve a genicular radiofrequency ablation. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not 
been met because the requested service is experimental/investigational. 
 
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 pre-approve a genicular radiofrequency ablation. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the requested service is considered an experimental/investigational 
procedure. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a radiofrequency ablation of the genicular nerves (64624).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on September 17, 2018. 
 
You asked the Plan to pay for the transportation services. You say that there was a misunderstanding. You say 
that you thought the claim had been filed with insurance. The Plan denied your request. The Plan says the claim 
was not received within 12 months of the date of service. 
 
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 the transportation services was not filed until October 11, 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 the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on September 17, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on August 13, 2021.
You asked the Plan to waive the copayment for ambulance transportation. You say that you were told that there would not be any bills after the date of the enrollee's death. You also say you did not receive this bill until September 27, 2021. The Plan denied your request. The Plan says the enrollee had 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 $260 copayment for ground ambulance services.
You have been asked to pay a $260 copayment for ambulance transportation. Ambulance transportation falls within the Ambulance Services 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 ambulance transportation provided on August 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing (D4342) provided on January 14, 2021.
You asked the Plan to pay for the dental services. You say that you received misinformation from the phone line about your dental plan. The Plan denied your request. The Plan says scaling and root planing is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the scaling and root planing is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the scaling and root planing (D4342) provided on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wire replacements (A4557), provided on July 15, 
2021. 
 
You asked the Plan to pay for the lead wire replacements. You say that you were not aware replacements of 
this item were not covered. The Plan denied your request. The Plan says you received this item with another 
item on the same date. 
 
The Plan must follow Medicare rules. Medicare rules say that Replacement of lead wires (A4557) more often 
than every 12 months would rarely be reasonable and necessary. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lead wire replacements have not been met. Therefore, we decided that the Plan does not have to 
pay for the lead wire replacements (A4557), provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) provided on June 15, 2021, by an outof-
network (OON) provider.
You asked the Plan to pay for an office visit. You say that prior authorization is not required for an office visit.
The Plan denied your request. The Plan says the claim was denied for unauthorized services. The Plan also says
that the member does not have out of network benefits and the services provider is not a participating provider
with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit (99204) provided on June 15, 2021, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing home care provided on July 7, 2021, through July 31, 2021.
You asked the Plan to pay for the nursing home care. You say that the hospice status was revoked. The Plan
denied your request. The Plan says Original Medicare continues to pay for services furnished after the
revocation or expiration of the enrollee's hospice election until the first day of the month after the hospice
election has been revoked or terminated.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 27, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the nursing home care provided on July 7, 2021, through July 31, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a home sleep test (G0399) rendered on July 13, 2021.
You asked the Plan to waive the copayment for a home sleep test. You say that since the provider made errors on the first study, you do not feel you should have to pay for the second one. 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 $210 copayment for each covered diagnostic procedure or test at a network outpatient facility. You have been asked to pay a $210 copayment for a home sleep test. Home sleep tests 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 copayment for a home sleep test (G0399) rendered on July 13, 2021.
Your complaint about the potential errors the provider made with the first home sleep test 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the temporomandibular disorder (TMD) therapy (D7899) provided on August 17, 2021.
You asked the Plan to pay for the TMD therapy. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is not a covered 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 temporomandibular disorder (TMD) therapy (D7899) provided on August 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient psychiatric care from March 2, 2022, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that additional time in this setting is necessary to build a safe discharge plan. The Plan denied your request. The Plan says as of March 2, 2022, the enrollee no longer meets the criteria for inpatient psychiatric care and can be stepped down to a less restrictive setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 continued inpatient psychiatric care. Our reviewer says that the health plan's denial of continued psychiatric care at the inpatient level appears appropriate in this case. Our physician reviewer found that this enrollee was admitted to the acute inpatient psychiatric hospitalization on February 3, 2022, with Schizophrenia, Unspecified and Major Neurocognitive Disorder, Unspecified with Behavioral Disturbance. Based upon a review the records provided, it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. This enrollee was compliant and cooperative with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. Based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of March 2, 2022, forward, and could have been treated in a lesser restrictive 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 continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient psychiatric care from March 2, 2022, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the i-SENS diabetic test strips and control solution (A4253 and A4256), and Sterilance Twist top lancets and the Sterilance lancing device (A4259 and A4258), provided on January 13, 2021.
You asked the Plan to pay for the diabetic supplies. You say that the member needs these items. The Plan denied your request. The Plan says there is no medical reason the member needs these items over the Plan's preferred items.
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands and manufacturers We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pay for the i-SENS diabetic test strips and control solution (A4253 and A4256), and Sterilance Twist top lancets and the Sterilance lancing device (A4259 and A4258), provided on January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 
28, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you contacted the Plan before this 
appointment and were advised that the cleaning would be covered. You also say that you cannot afford this bill. 
The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan. 
The Plan also says that the call you made to the customer service department was reviewed and you were given 
correct information about the cleaning. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, periodontal maintenance (D4910) is 
limited to three procedures per plan year. The record shows that you received a periodontal maintenance 
(D4910) on February 16, 2021, May 20, 2021, and July 22, 2021 and your periodontal maintenance (D4910) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodontal 
maintenance (D4910) provided on October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on August 27, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the referring provider is also non-participating with the Plan. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.
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 an office visit (99213) provided on August 27, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an elliptical (E1399), provided on October 6, 2021.
You asked the Plan to pay for an elliptical. You say that the item should be covered. The Plan denied your request. The Plan says this item is not covered when purchased out-of-network.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for an elliptical (E1399), provided on October 6, 2021.