Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services or home with outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and refraction provided on May 19, 2021 and the progressive lenses provided on May 25, 2021.
You asked the Plan to pay for the eye exam, refraction, and progressive lenses. You say that the original hospital did not have an eye surgeon, so you went to another hospital. You say that you had to go out-of-network and insurance failed when you needed it most. 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 routine vision services when they are received by a Plan vision provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eye exam, refraction, and progressive lenses have not been met. Specifically, the services were not received by a Plan provider. Therefore, we decided that the Plan does not have to pay for the eye exam and refraction provided on May 19, 2021 and the progressive lenses provided on May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous (IV) tubing extension set rendered on June 14, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Billed procedure code S1015 (IV tubing extension set) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the intravenous (IV) tubing extension set rendered on June 14, 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 June 25, 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 June 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210), core build up (D2950), 
and crown (D2750) provided on August 31, 2021.

You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that 
you had $1,000 for dental coverage. You also say that the provider gave you a list of what would be covered.
The Plan denied your request. The Plan says complete series x-ray is not listed as a covered service. The Plan 
says that core build up is not listed as a covered service. The Plan also says that crown is not listed as a covered 
service either.

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 complete series x-ray, core build 
up, and crown are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the complete series x-ray (D0210), core build up (D2950), and crown (D2750) provided on 
August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections provided on August 2, 2021, and September 13, 2021.
You asked the Plan to waive the coinsurance for the Part B injections. You say that you do not agree with the cost of the injection. The Plan denied your request. The Plan says you have been asked to pay 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 20% coinsurance for Medicare-covered Part B drugs and other Medicare-covered items.
You have been asked to pay $522.24 which is 20% of the allowed amount for the Part B injection on each date of service. The allowed amount is $2,611.20. ($2,611.20 x 20% = $522.24). The Part B injections fall within the "Medicare Part B prescription 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 Part B injections provided on August 2, 2021, and September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2331) provided on October 5, 2021.
You asked the Plan to pay for the resin-based composite. You say that you feel that you pay enough for the insurance and that a filling should be covered. The Plan denied your request. The Plan says this service is not covered.
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 resin-based composite (D2331) provided on October 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a flex-foot system (L5980), multiaxial rotation unit (L5986), and flexible protective outer surface covering system (L5962).

You asked the Plan to pre-approve a flex-foot system, multiaxial rotation unit, and flexible protective outer surface covering system. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that prosthesis accessories are covered when specific criteria are met. 

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 flex-foot system, multiaxial rotation unit, and flexible protective outer surface covering system. Our reviewer says that the items are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that you meet the coverage criteria detailed in the Local Coverage Article: Lower Limb Prostheses - Policy Article, A52496 for the requested durable medical equipment. Records do not clearly document that you are a K3 level ambulator to meet criteria for the requested L5980 - All lower extremity prostheses, Flex-Foot system and L5986 - All lower extremity prostheses, multiaxial rotation unit; records indicate you require a walker and power wheelchair at times. This is not consistent with a K3 level of function. Records do not document you are exposed to such harsh environmental conditions that the L5962 flexible protective outer surface covering system is needed. 

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 flex-foot system, multiaxial rotation unit, and flexible protective outer surface covering system have not been met. Therefore, we decided that the Plan does not have to pre-approve a flex-foot system (L5980), multiaxial rotation unit (L5986), and flexible protective outer surface covering system (L5962).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits, and diagnostic services provided from June 22, 2021, to July 22, 2021.

You asked the Plan to waive the copayments for the specialist office visits and diagnostic services. You say that you are appealing these bills. You say you are unsure of the justification for the charges. The Plan denied your request. The Plan says you have been asked to pay 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 $40 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office, a $30 copayment for Medicare-covered non-radiological diagnostic services. Examples include, but are not limited to electrocardiograms, pulmonary function tests, home or lab-based sleep studies, and treadmill stress tests, and a $75 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). 

You have been asked to pay $197.62 for the specialist office visits and diagnostic services. The specialist office visits fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The diagnostic services fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. 

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the specialist office visits and diagnostic services provided from June 22, 2021, to July 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee can get the therapy needed at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care
needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for IRF care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Meningococcal vaccines and administration (90620, 
90734, and 90472) provided on May 31, 2021.

You asked the Plan to pay for the Meningococcal vaccines and administration. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Meningococcal 
vaccines and administration. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the Meningococcal 
vaccines and administration. Therefore, we decided that the Plan does not have to pay for the Meningococcal 
vaccines and administration (90620, 90734, and 90472) provided on May 31, 2021.

Benefits for the Meningococcal vaccines and administration may be available under Medicare Part D. Contact
the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), additional periapical x-rays (D0230 x 5), and panoramic x-ray (D0330) provided on August 5, 2021.
You asked the Plan to pay for the dental services. You say that your appointment was only for an oral exam and cleaning. You say that the provider did a bunch of x-rays that you did not approve. You say that you were advised there would be no bill for the services that you received. You also say that you received a bill for $422. You also say that you never received a dental cleaning. The Plan denied your request. The Plan says periapical x-rays are not listed as covered services. The Plan says that panoramic x-ray is not listed as a covered service either.
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 periapical x-rays and panoramic x-ray are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), additional periapical x-rays (D0230 x 5), and panoramic x-ray (D0330) provided on August 5, 2021.
Your complaint about the services you received 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services provided on May 29, 2021.
You asked the Plan to pay for the air ambulance services. You say that the air ambulance transport provided on
May 29, 2021 was medically necessary. The Plan denied your request. The Plan says the air ambulance
transport provided on May 29, 2021 was not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your
medical condition is such that transportation by ground ambulance is not appropriate.
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 air ambulance services. Our reviewer
says that the air ambulance transport provided on May 29, 2021 was not medically necessary. Our physician
reviewer found the review has determined that the documentation did support that the enrollee suffered from an
illness or injury that contraindicated transportation by any means other than ambulance. The documentation did
not support that the enrollee's condition was such that the time needed to transport a patient by ground, or the
instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the
enrollee's health.
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 air ambulance services have not been met. Therefore, we decided that the
Plan does not have to pay for the air ambulance services provided on May 29, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the magnetic resonance imaging (MRI) of the upper extremity joint, without contrast (73221) provided on May 14, 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 that the service was denied as the provider specialty indicated is invalid. Additionally, the service was rendered by an out-of-network provider.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not indicated who the referring provider was for the service rendered in this case. Additionally, there is no supportive evidence provided regarding the denial issued on the basis of an invalid provider specialty indicated. Therefore, we decided that the Plan has to pay for the magnetic resonance imaging (MRI) of the upper extremity joint, without contrast (73221) provided on May 14, 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on August 26,
2019.
You asked the Plan to pay for the physician service. You say that your coding department reviewed the level of
emergency evaluation and concluded that the coding used was at best as per the medical condition. The Plan
denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in
which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the emergency department visit provided on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on August 10, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for the copayment because your prescription was not filled. The Plan denied your request. The Plan says you have been asked to pay 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 $50 copayment for specialist visits. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you received evaluation and management services during the office 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 specialist office visit provided on August 10, 2021.
Your complaint about being discriminated against 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