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

We decided that the Plan does not have to pay for a mammogram provided on July 2, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the mammogram. You say that mammograms typically do not need prior authorization. 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 mammogram provided on July 2, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for DME and related supplies provided on September 12, 2020.
You asked the Plan to waive the deductible for DME and related supplies. You say that you could pay less from other providers. 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. Your contract with the Plan says that there is a $200 deductible which applies to DME and related supplies. You received DME and related supplies on September 12, 2020. The record shows that you had only paid $14.86 toward the $200 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $185.14.
The item or service you asked the Plan to waive the deductible for falls within the benefit category DME and related supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $200 deductible which applies to DME and related supplies. This cost sharing is a contractual obligation that had not been met at the time DME and related supplies was received on September 12, 2020. Therefore, we decided that the Plan does not have to waive the deductible for DME and related supplies provided on
September 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided April 8, 2021.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider does not participate in the Medicare program and is ineligible for payment.
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 the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office visit (99203) provided April 8, 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 April 16, 2021.,
You asked the Plan to pay for the ambulance service. You say that per the attached ambulance report, the enrollee was not transported. The ambulance claim pertains to the service provided. The Plan denied your request. The Plan says this service is not covered as there was not transport services provided.
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 16, 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 April 16, 2021.,
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for upper immediate denture, includes limited follow-up care
only (D5130) provided July 8, 2021.
You asked the Plan to pay for the dental service. You say that you spoke to the dentist office to make sure that
you were covered for this procedure. Before getting the procedure, you made a payment of $1,363.90. You are
not refusing to pay but you do not agree to pay the full amount. The Plan denied your request. The Plan says
this service is not covered under the Plan benefits.
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 upper
immediate denture, includes limited follow-up care only (D5130) provided July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for full hereditary cancer screening panel provided on August 14, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is non-covered screening.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for full hereditary cancer screening panel provided on August 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307) provided June 11, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allowed frequency.
The Plan must follow Medicare rules. Medicare rules say that Medicare will consider presumptive drug testing in excess of 12 per Calendar year not reasonable and necessary. We looked at the file and Medicare rules. More than 12 drug tests were billed in the calendar year. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307) provided June 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided
June 30, 2021 to July 2, 2021.
You asked the Plan to waive the copayment for the inpatient services. You say that you received notice that the
hospitalization and subsequent treatments were denied and you are asking for reconsideration of the decision.
The Plan denied your request. The Plan says this claim was processed with the correct copayment applied per
the Evidence of Coverage.
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 $160
copayment per day, days 1-10 for Inpatient hospital care.
You have been asked to pay $150.35 for the inpatient services. Since the allowed amount is less than the
copayment amount, you are responsible for the lesser amount. The inpatient services fall within the Inpatient
hospital care benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital
services provided June 30, 2021 to July 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided July 3, 2021 - July 6, 2021.
You asked the Plan to pay for the SNF services. You say that you feel that the Plan should cover for the SNF services. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of coverage were not 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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided July 3, 2021 - July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D1110, D0272 and D0120) provided on June 3, 2021.
You asked the Plan to pay for the dental services. You say that you would like reconsideration because you have been seeing this dentist for 10 years and these services should be covered for your continuity of care. The Plan denied your request. The Plan says this dentist has opted out of Medicare.
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 because they were rendered by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the dental services (D1110, D0272 and D0120) provided on June 3, 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.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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. Our physician reviewer found there is no documentation provided indicating medical necessity for LTACH services. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis.
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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Incobotulinum Toxin A (Botox) injection you received on April 12, 2021.
You asked the Plan to waive the coinsurance for the Botox injection. You say that this injection was supposed to be a sample, so there should not be a charge. You also stated that a Plan representative told you that Botox injections would only be charged a $40. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that there is no documentation to show that you were told this injection would only be $40.
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 20% coinsurance for Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the Botox injection. The Botox injection falls within the Medicare Part B drugs 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 coinsurance for the Incobotulinum Toxin A (Botox) injection you received on April 12, 2021.
Your complaint about the doctor's office not using a sample 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient rehabilitation services provided
from April 10, 2021, to April 13, 2021.
You asked the Plan to waive the coinsurance for outpatient rehabilitation services. You say that the services did
not help your condition. 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 50%
coinsurance for out-of-network outpatient rehabilitation services.
You received outpatient rehabilitation services from an out-of-network provider from April 10, 2021, to April
13, 2021. Therefore, you are responsible to pay your share of the out-of-network charges. The total allowed
amount is $193.83 and 50% of that is $96.89.
You have been asked to pay the total coinsurance amount of $96.89 for outpatient rehabilitation services.
Outpatient rehabilitation services fall within the outpatient rehabilitation 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 coinsurance for outpatient rehabilitation services provided from April 10, 2021, to
April 13, 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 August 13, 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 August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewing x-ray, additional intraoral x-ray and panoramic x-ray provided on May 4, 2021.
You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-ray, additional intraoral x-ray, and panoramic x-ray. You say that you only had these procedures done once this year. The Plan denied your request. The Plan says reimbursement has already been issued for these services which exhausted your benefits.
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, you also have a maximum benefit of one comprehensive oral evaluation every three years, one set of bitewing x-rays per calendar year, one intraoral x-ray per calendar year and one complete series or panoramic x-ray every five years. The Plan paid for the comprehensive oral evaluation and intraoral complete series x-ray provided on September 1, 2020, one intraoral x-ray provided on May 4, 2021 and the bitewing x-ray provided on July 1, 2021, which exhausted your benefits. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewing x-ray, additional intraoral x-ray and panoramic x-ray provided on May 4, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for unclassified drugs provided to the enrollee on July 2, 2020.
You asked the Plan to pay for the drug. You say that this should be paid for. The Plan denied your request. The
Plan says the denied code remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code J3490 is "Unclassified drugs."
We asked our coder 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 the drug. Our reviewer says that the services at issue in this
case were not supported by the medical records. Our reviewer found the four units of service provided cannot
be verified. Each component of a nutria-pharmaceutical blend would not be reported separately, and therefore
three of the four units billed would not be covered.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have
to pay for unclassified drugs provided to the enrollee on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on July 14, 2021 by an out-of-network (OON) provider.
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 medical services provided to the enrollee on July 14, 2021 by an out-of-network (OON) provider
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for WATS3D testing provided on April 29, 2021.
You asked the Plan to pay for laboratory testing. You say that this testing was ordered by the enrollee's treating physician after a determination of medical necessity. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing was not medically necessary.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This testing was ordered by an in-network provider. The file does not show that the plan provided notice that laboratory testing would not be covered. Under Medicare rules, this means laboratory testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for WATS3D testing provided on April 29, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307) provided July 6, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of times this service was billed exceeds the allowable frequency.
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 code 80307 is not supported in the medical record. Specifically, the frequency with which this service was billed exceeds the allowable amount per Local Coverage Determination (LCD): Controlled Substance Monitoring and Drugs of Abuse Testing (L35006). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307) provided July 6, 2021.