Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health office visits provided on May 28, 2021 to June 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visits. You say that you were told that the provider was in-network. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the outpatient mental health office visits provided on May 28, 2021 to June 11, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on December 6 to December 7, 2019, by a provider not enrolled in the Medicare program.
You asked the Plan to pay for home health services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services 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 home health services provided on December 6 to December 7, 2019, by a provider not enrolled in the Medicare program.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (RFA).
You asked the Plan to pre-approve lumbar RFA. You say that you cannot concentrate with your pain and need this procedure done as soon as possible. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you previously had lumbar RFA on March 16, 2021 and March 17, 2021 so you have exhausted the two sessions per spinal region per 12 rolling months.
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be covered per 12 rolling months. We looked at the file and Medicare rules. You previously received lumbar RFA sessions on March 16, 2021 and March 17, 2021, therefore the covered benefit for RFA of this spinal region is exhausted at this time. Based on this information, we decided that Medicare rules for coverage of lumbar RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing rendered on April 19, 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 were billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing rendered on April 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on November 26, 2019.
You asked the Plan to pay for the physical therapy services. You say that the medical records required to reprocess the denied claim are attached. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 7, 
2021. 
 
You asked the Plan to pay for the dental service. You say that you thought your insurance covered preventive 
services. You say that you though your extra dental coverage covered non-preventive care. You also say that 
you were told it would be covered at 80% for all visits related to your root canal. The Plan denied your request. 
The Plan says 2 oral exams are covered per calendar year. The Plan also says that the frequency limit has been 
exceeded. 
 
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 frequency limit has been exceeded. 
The record shows that the Plan paid for oral exams that you received on April 7, 2021, and May 14, 2021. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on 
June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based fillings (D2331, D2332) provided on June 23, 2021.
You asked the Plan to pay for the fillings. You say that you believed these services were covered and feel you have been misled. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based fillings (D2331, D2332) provided on June 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428), ground
mileage (A0425), and the basic support routine supplies (A0382) provided on September 15, 2020.
You asked the Plan to pay for the transportation services. You say that the services should be covered. The Plan
denied your request. The Plan says the transportation service was not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 transportation services. Our reviewer
says that the transportation services are not medically necessary.
Our physician reviewer found the provided documentation did not support that other means of transport (such
as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee
on September 15, 2020. The reviewer found that the documentation did not support that the enrollee needed the
expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can
provide for safe transport on September 15, 2020. The documentation did not support that the ambulance
transport on September 15, 2020, was medically reasonable and necessary for the enrollee.
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 transportation services have not been met. Specifically, the file does not
support that other means of transport were contraindicated for the enrollee. Therefore, we decided that the Plan
does not have to pay for the non-emergency ambulance transport (A0428), ground mileage (A0425), and the
basic support routine supplies (A0382) provided on September 15, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy provided from December 1, 2020, through May 14, 2021.
You asked the Plan to pay for occupational therapy. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 occupational therapy provided from December 1, 2020, through May 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 March 11, 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 March 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and
services provided May 12, 2021, through May 20, 2021.
You asked the Plan to waive the copayment for the inpatient hospital admission. You say that you do not have
the means to pay the high cost of the services. The Plan denied your request. The Plan says the copayment was
applied 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 $490
copayment per day, days 1-4 for inpatient hospital care.
You have been asked to pay a total of $1,470 ($490 copayment x 3 days = $1,470) for the inpatient hospital
admission. The inpatient hospital admission falls 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 admission and services provided May
12, 2021, through May 20, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the $90 copayment charged for emergency room services 
provided on June 24, 2021. 
 
You asked the Plan to waive this copayment. You say that you thought this was an urgent care facility. The 
Plan denied your request. The Plan says this clinic provides traditional physician, urgent care and emergency 
room services. The provider confirmed that you received emergency room services and billed the claim 
appropriately. 
 
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 $90 
copayment for emergency room services. 

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 $90 copayment charged for emergency room services provided on June 24, 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 transfer to an LTACH is medically 
necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an 
LTACH are not met. The enrollee is receiving appropriate acute care in the current hospital facility and can 
remain in this location until no further acute care is needed. 
 
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 admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. There are no services available at the LTACH that the enrollee requires 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 the diagnosis and 
condition of the enrollee 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: 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 
May 17, 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 May 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on January 26, 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 that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on January 26, 2021.
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a wellness visit (G0439) provided June 16, 2021.
You asked the Plan to pay for the annual wellness visit. You say that the claim should be covered as you needed to find a new primary care provider. The Plan denied your request. The Plan says the benefit was exhausted at the time the service was rendered.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for a wellness visit (G0439) provided June 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac tracing services (93229) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the cardiac tracing services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says there are network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve cardiac 
tracing services (93229) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression stockings (A6530).
You asked the Plan to pre-approve gradient compression stockings. You say that the item is necessary. The Plan denied your request. The Plan says the item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that some wound care items which are non-covered under the surgical dressing benefit. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of gradient compression stockings have not been met. Therefore, we decided that the Plan does not have to pre-approve gradient compression stockings (A6530).
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 15, 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 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation mileage. 
 
You asked the Plan to provide coverage for additional routine transportation mileage. The Plan denied your 
request. The Plan says you are requesting an additional 72 miles for a total of 122 miles. Your benefit only 
allows 50 miles. You have exceeded your benefit limit. 
 
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.

We looked at your request, the records in the case file, and the rules. The file shows that the Plan benefit allows 
for 50 miles, and you are requesting a total of 122 miles. Therefore, we decided that the Plan does not have to 
provide coverage for additional routine transportation mileage.
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 16, 2021.
You asked the Plan to pay for this service. 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 16, 2021.