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

We decided that the Plan does not have to pay for the drug testing services (G0482) provided on April 19, 2021
by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says these services were not urgent, emergent,
ordered by a network physician or approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the drug testing services (G0482) provided on
April 19, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on October 15,
2021.
You asked the Plan to waive the copayment for an office visit. You say that this was your annual wellness
exam, and you should not owe a copayment. 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 a $10
copayment for primary care provider visit.
The medical records show that you had an office visit on October 15, 2021, that went beyond an annual
wellness exam. Furthermore, at the time services were received, the annual wellness exam benefit was
exhausted, and you were not eligible for an annual wellness exam until November 16, 2021. Therefore, you are
responsible to pay the $10 copayment.
You have been asked to pay a $10 copayment for an office visit. An office visit falls within the
physician/practitioner services, including doctor's office visits benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for an office visit provided on October 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Acthar injection 80 units for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request is on the self-administered drug list and is excluded from coverage under 
Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Acthar injection 80 units for 
the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lens fitting provided on September 17, 2021.

You asked the Plan to pay for contact lens fitting. The Plan denied your request. The Plan says you do not have 
out-of-network benefits and there is no indication that attempts were made to obtain 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 contact lens fitting provided on September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits, an ECG, myocardial
perfusion imaging, and a stress test and does not have to waive the coinsurance for medical supplies and a
Medicare Part B drug provided from July 20, 2021, to August 17, 2021.

You asked the Plan to waive the copayments for office visits, an ECG, myocardial perfusion imaging, and a
stress test and to waive the coinsurance for medical supplies and a Medicare Part B drug.

You say that you were told that you would not owe anything for services relating to the coronavirus. 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 a $35
copayment for specialist visits, a $20 copayment for outpatient diagnostic tests, a $110 copayment for nuclear
studies, and 20% coinsurance for medical supplies and Medicare Part B prescription drugs.

You received office visits, an ECG, myocardial perfusion imaging, a stress test, medical supplies and a
Medicare Part B drug provided from July 20, 2021, to August 17, 2021. The record shows that these services
do not qualify for a coronavirus waiver. Therefore, you are responsible to pay your share of the cost-sharing
charges. Please see the chart below.

Date of Service Service Allowed Amount Amount You Owe

7/20/2021 99214 $123.22 $35
7/20/2021 93000 $14.06 $14.06
8/9/2021 78452 $323.46 $110
8/9/2021 93015 $58.52 $20
8/9/2021 A9500 $680.00 $136
8/9/2021 J1245 $21.18 $4.24
8/17/2021 99213 $86.75 $35

The total amount you owe is: $354.30.

You have been asked to pay the total amount of $354.30 for office visits, an ECG, myocardial perfusion
imaging, a stress test, medical supplies and a Medicare Part B drug. Office visits fall within the
physician/practitioner services, including doctor's office visits benefit category. An ECG, myocardial perfusion
imaging, a stress test and medical supplies fall within the outpatient diagnostic tests and therapeutic services
and supplies benefit category. Medicare Part B drugs 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 copayments for office visits, an ECG, myocardial perfusion
imaging, and a stress test and does not have to waive the coinsurance for medical supplies and a Medicare Part
B drug provided from July 20, 2021, to August 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the enrollee's medical and therapy needs could be met in a skilled nursing unit.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen (15) hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on
September 10, 2021, through September 22, 2021.

You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service should be
covered. The Plan denied your request. The Plan says the cost share 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 $492
copay for each day one through four for inpatient hospital care.

You have been asked to pay a $492 copay for each day one through four for the inpatient hospital care. This
service 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 care provided on
September 10, 2021, through September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 20, 2021.
You asked the Plan to pay for the dental service. You say that you were referred to this dentist by your primary care physician (PCP). You also say that this should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that services obtained from vendors outside this network are 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 dental services obtained out of
network are not among those covered under this benefit. Additionally, the Plan confirmed with the dental provider that there was no referral on file from your primary care physician. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement provided on September 8, 2021 by an out-
of-network (OON) provider.
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 rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The 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 debridement provided on September 8, 2021
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs or medicaments for take home use (D9630)
provided on April 29, 2021.

You asked the Plan to pay for the dental service. You say that you were undergoing radiation therapy. You say
that the dental services you received were necessary to prevent tooth decay from the radiation therapy. You
also say that you believe this is a medical claim since radiation therapy is covered under the medical plan. The
Plan denied your request. The Plan says drugs or medicaments for take home use 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 the drugs or medicaments for take home use (D9630) provided on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate upper denture (D5130), immediate lower
denture (D5140), and unspecified adjunctive procedures (D9999 x 2) provided on August 16, 2021.

You asked the Plan to pay for the unspecified adjunctive procedures. You say that a plan representative told
you this dental office was in network. You say that you were advised the services would be covered. You say
that you now have no teeth and nothing to eat with. You also say that you are upset because you were told that
the plan would pay this bill. The Plan denied your request. The Plan says unspecified adjunctive procedures are
not listed as covered services.

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 unspecified adjunctive procedures
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for
the immediate upper denture (D5130), immediate lower denture (D5140), and unspecified adjunctive
procedures (D9999 x 2) provided on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided to you by an out-ofnetwork
provider from August 25, 2021, to October 19, 2021.

You asked the Plan to pay for the acupuncture services. You say that there were no in-network providers
available. The Plan denied your request. The Plan says the services were not authorized.

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 services at issue in this appeal. 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 the acupuncture services provided to you by an out-of-network
provider from August 25, 2021, to October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an
established patient (99349) rendered by an out-of-network (OON) provider on June 2, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
You are not a network provider with the Plan. The Plan had network providers available who could have
provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the home visit for the evaluation and management of an established patient (99349)
rendered by an out-of-network (OON) provider on June 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on 
November 10, 2020, through November 17, 2020
.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service should be 
covered. The Plan denied your request. The Plan says the cost share 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 $325 
copay each day one through five for inpatient hospital care.
 
You have been asked to pay a $325 copay each day one through five for the inpatient hospital care. This 
service 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 care provided on November 10, 2020, through November 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment rendered on
August 17, 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 not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 31 for a
skilled nursing facility (SNF) setting; however, the file shows that the enrollee was not in a covered SNF stay
and the POS code should be billed as 32. Therefore, we decided that the Plan does not have to pay for the
transportation of portable x-ray equipment rendered on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99379) provided on May 28, 2021.

You asked the Plan to pay for nursing facility care. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database 
(MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment 
for other services not specified.

We looked at the file and Medicare rules. Code 99379 has a status indicator of B and is not separately payable. 
Based on this information, we decided that Medicare rules for coverage of nursing facility care have not been 
met. Therefore, we decided that the Plan does not have to pay for nursing facility care (99379) provided on 
May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture rebase (D5710).
You asked the Plan to pre-approve the complete upper denture rebase (D5710). You say that the dentures are
not fitting properly, and you cannot eat without them. You say that the dentist informed you he couldn't take
back the claim to reimburse the dentures. 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 pre-approve the
complete upper denture rebase (D5710).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.

You asked the Plan to pay for 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's status is stable and improving. The enrollee is receiving medically necessary care at the current facility and does not have clinical conditions that cannot be appropriately treated in the current hospital. There are no issues for which an LTACH may offer a therapeutic advantage.

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 pay for 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 the record indicates that the enrollee is improving. The enrollee is receiving ongoing acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available in the LTACH facility. The elements of the coverage rules are not satisfied; the requested service cannot be 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 9, 2021 by an out-of-network (OON) provider.

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 rendered by an out-of-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The 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 laboratory services provided on September 9, 2021 by an out-of-network (OON) provider.