Persius/hicric huggingface dataset:
Appeal type: Transportation
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 you have used all of the available 50 one-way trips allowed under your contract.  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 a maximum of 50 one-way trips per year.      We looked at your request, the records in the case file, and the rules. The file shows that you have used all of the available 50 one-way trips this year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the eyewear provided on May 13, 2021.   You asked the Plan to pay more for the eyewear. You say that the $250 allowance was deducted from the submitted amount instead of the approved amount. You disagree with this decision and you may leave the Plan if this is not corrected. The Plan denied your request. The Plan says the claim processed correctly.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $250 per calendar year toward the purchase of either one pair of eyeglasses or contact lenses.  We looked at the file and the Plan's rules. Specifically, the Plan paid the full maximum allowance of $250 toward the purchase of the eyewear. Based on this information, we decided that the Plan's rules for additional coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay more for the eyewear provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more toward the intraoral x-ray and limited oral evaluation provided on July 22, 2021.  You asked the Plan to pay more toward the intraoral x-ray and limited oral evaluation. The Plan denied your request. The Plan says the claim processed correctly.  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 Plan is only obligated to pay 50% of the allowed amount for the intraoral x-ray. You are responsible for the remaining cost of the intraoral x-ray as it was received from an out-of-network provider. You are also responsible for the full cost of the limited oral evaluation as it is not a covered benefit. Therefore, we decided that the Plan does not have to pay more toward the intraoral x-ray and limited oral evaluation provided on July 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for an outpatient hospital clinic visit provided on June 28, 2021.  You asked the Plan to pay for an outpatient hospital clinic visit. The Plan denied your request. 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 Plan says that the Plan has 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 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 an outpatient hospital clinic visit provided on June 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for vision care services you received in a specialist's office on August 11, 2021.  You asked the Plan to waive the copayment for the vision care services. You say that there should be no copayment because these services were performed by a technician.  You said that you did not see a doctor or a specialist. 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 $35 copayment for vision care services in a specialist's office.   You have been asked to pay a $35 copayment for the vision care services. There is no requirement in your contract that you have to see a doctor in order for the vision care copayment to apply.  The Evidence of Coverage explicitly states that for any vision care services rendered in a specialist's office (as was the case here), the $35 copayment applies. 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 vision care services you received in a specialist's office on August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical first radiographic image (D0220), an intraoral complete series of radiographic images (D0210), a fixed partial denture sectioning (D9120), inhalation of nitrous oxide (D9230) and three (3) teeth extractions (D7210) provided on March 23, 2021, to March 31, 2021.  You asked the Plan to pay for dental services. You say that you were in a lot of pain and you were sent home with an antibiotic due to an infection. You also say you are requesting reconsideration for the total amount of the claim. The Plan denied your request. The Plan says the services at issue are not covered.  Medicare generally does not cover dental services. The Plan follows the same rule.    The services you are asking the Plan to pay 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 pay for a limited oral evaluation (D0140), an intraoral periapical first radiographic image (D0220), an intraoral complete series of radiographic images (D0210), a fixed partial denture sectioning (D9120), inhalation of nitrous oxide (D9230) and three (3) teeth extractions (D7210) provided on March 23, 2021, to March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for oral nutritional supplements purchased from May 29, 2021 to June 26, 2021.  You asked the Plan to pay for Boost nutritional supplements. You say that these supplements should be covered by the Plan. The Plan denied your request. The Plan says this type of oral supplement is not covered by Medicare.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pay for are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pay for oral nutritional supplements purchased from May 29, 2021 to June 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services provided on June 10, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the anesthesia services. You say that the enrollee did not have the knowledge that the in-network surgeon utilized an out-of-network anesthesiologist. 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. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on June 10, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the peroral endoscopic myotomy (POEM) procedure.  You asked the Plan to pre-approve POEM procedure. You say that these services are medically necessary. The Plan denied your request. The Plan says the requested procedure is considered investigational for the enrollee's condition.  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 POEM procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the enrollee has gastroparesis. There is insufficient literature to support the use of the requested procedure for the enrollee's condition. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of POEM procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the peroral endoscopic myotomy (POEM) procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the re-cement and re-bond of crown provided on August 9, 2021.  You asked the Plan to pay for the re-cement and re-bond of crown. You say that you want the crown covered and also want medication. The Plan denied your request. The Plan says the 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 re-cement and re-bond of crown provided on August 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that the member will require another 2-3 weeks to continue weaning protocols and transition from his acute illness. The Plan denied your request. The Plan says that records show the enrollee does not have a condition complex enough to require continued inpatient care with daily doctor visits and specialized nursing for more than 25 days.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient appears to be improving and more stable requiring only short-term additional acute care services that can be safely administered at the current facility. The patient does not require LTACH services that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a CPAP device (E0601) provided on June 17, 2021.  You asked the Plan to pay for a CPAP device. You say that you had to purchase the CPAP device at issue because your prior CPAP device was affected by a recall. The Plan denied your request. The Plan says rules for payment have not been met because the supplier of the item at issue is not enrolled in the Medicare program.  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 a CPAP device (E0601) provided on June 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee's condition is chronic, and the type of care needed is custodial in nature. The Plan says that the enrollee does not require nursing from a licensed nurse or rehabilitative services on a daily basis.  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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on May 10, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.  The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.   We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 10, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on May 11, 2021.  You asked the Plan to pay for 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. 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 May 4, 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 physician's services provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the surgical extraction (D7210) provided on June 5, 2021.  You asked the Plan to pay more for the surgical extraction (D7210). You say that a surgical extraction was billed but he only did a simple extraction. The Plan denied your request. The Plan says the copayment applied correctly.  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 claim processed correctly applying a $75 copayment to the surgical extraction that was billed. Therefore, we decided that the Plan does not have to pay more for the surgical extraction (D7210) provided on June 5, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pay for continued skilled nursing facility (SNF) services after November 7, 2020.  You asked the Plan to pay for SNF care. The Plan denied your request. The Plan says that continuation of SNF care is not medically necessary.  The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.  We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before November 7, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pay for continued SNF services after November 7, 2020.   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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient mental health care you received from October 11, 2020, to October 15, 2020.  You asked the Plan to waive the copayment for the inpatient mental health care. You say that you feel as if you didn't need to be in that facility so you shouldn't have to pay the copayment. 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 $250 copayment per day for days 1-5 for inpatient mental health care.   Records show that you were in the facility for 4 days.  You were charged a $250 copayment per day, for a total of $1000.  This copayment applies regardless of the reason for your stay. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient mental health care you received from October 11, 2020, to October 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power operated vehicle and accessories.  You asked the Plan to pre-approve a power operated vehicle and accessories. You say that this equipment is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the notes say the enrollee is able to use a manual wheelchair to complete activities at home.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The item at issue in this appeal is for use outside of the home. Specifically, the medical documentation indicates this power wheelchair will be used primarily outside the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle and accessories.