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

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that if the enrollee does not get the rehabilitation, she needs in a SNF she will not be able to go home and be with family. The appellant says that SNF care will allow the enrollee to regain her strength. The Plan denied your request. The Plan says the requirements for approval of SNF care have not been met. The Plan says that the enrollee can safely receive the services needed in the current hospital setting.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and tested positive for coronavirus. The enrollee received physical therapy but did not participate with therapy. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient physical therapy (PT) services provided on September 20, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the outpatient PT services. You say that you checked with the provider in advance that you were covered. You say that the provider indicates that you had coverage. You say that you asked if you need a referral. You also say that you were advised a referral was not needed. The Plan denied your request. The Plan says the services rendered could have been provided in network.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the outpatient PT services at issue in this appeal. The Plan did not pre-approve the outpatient PT service at issue. We found no exception that would require the Plan to pay for these outpatient PT services. Therefore, we decided that the Plan does not have to pay for the outpatient physical therapy (PT) services provided on September 20, 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 complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided December 1, 2020.  You asked the Plan to pay for the complete upper and lower dentures. You say that you were given misinformation from the dentist about coverage and ended up dissatisfied with your dentures. The Plan denied your request. The Plan says these services are not covered when they are provided out-of-network. 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. The Plan does not cover service that are rendered by a nonparticipating dentist.  We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the complete upper and lower dentures have not been met. Therefore, we decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a provisional crown, further treatment or completion of diagnosis necessary prior to final impression (D2799) provided on August 17, 2021.  You asked the Plan to pay for a provisional crown. You say that a check was sent to the provider in error after you paid for the dental services in cash. You also say the provider does not accept your Plan and should not have received a check and instead, the check should be redirected. The Plan denied your request. The Plan says the service requested is not a covered benefit with your Plan.  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 a provisional crown, further treatment or completion of diagnosis necessary prior to final impression (D2799) provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for eyeglasses provided on June 23, 2021.  You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says the claim was processed correctly.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by a network optical provider.  We looked at the file and the Plan's rules. The file shows that the claim was processed correctly based on your vision benefit. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on June 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ultrasound, transrectal (76872) provided August 25, 2021.  You asked the Plan to waive the copayment for the transrectal ultrasound. You say that you don't know what procedure this copayment is for. 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 $10 copayment for other diagnostic tests.         You have been asked to pay a $10 copayment for the transrectal ultrasound which was performed during a guided needle biopsy. The transrectal ultrasound falls 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 copayment for the ultrasound, transrectal (76872) provided August 25, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdomen ultrasound rendered on August 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 procedure code 76705 is not supported.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.     The provider submitted a claim for procedure codes 76705 (abdomen ultrasound) and 93976 (vascular study). Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 76705 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the abdomen ultrasound rendered on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for telephone evaluation and management service, 21-30 minutes (99443) provided April 5, 2021 to June 25, 2021.  You asked the Plan to pay for the telephone visit. You say that the telemed appointment was due to COVID restrictions. The Plan denied your request. The Plan says the services were rendered by a provider who is not certified with Medicare.  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 telephone evaluation and management service, 21-30 minutes (99443) provided April 5, 2021 to June 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost share for the PET scan provided on September 30, 2021.  You asked the Plan to waive the cost share for the PET scan. You say that the injection you received was the PET scan, and it was medically necessary in order to catch the cancer in your bones. 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. Your contract with the Plan says that there is $800 deductible which applies to advanced imaging services at an in-network outpatient hospital and a $180 copayment for advanced imaging services at an in-network outpatient hospital.   The PET scan you asked the Plan to waive the cost share for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $800 deductible which applies to the PET scan and a $180 copayment. See chart below.  Date of Service Service Allowed Amount Deductible/Copayment Member Liability September 30, 2021 PET Scan $1,794.85 $800 $800  PET Scan $994.85 -This is the remaining allowed amount after the deductible was applied. ($1,794.85 - $800) $180 $180 Total    $980  This cost sharing is a contractual obligation that had not been met at the time the PET scan was received on September 30, 2021. Therefore, we decided that the Plan does not have to waive the cost share for PET scan provided on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on  September 2, 2021.  You asked the Plan to pay for a limited oral evaluation. You say that you are requesting a reconsideration of the denied charges. The Plan denied your request. The Plan says the service is not a covered benefit with your Plan.  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 a limited oral evaluation (D0140) provided on September 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided April 27, 2021.  You asked the Plan to waive the copayment for the emergency ambulance services. You say that you called member services and were told if you left the hospital without seeing a doctor you would not be charged for anything. 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 $280 copayment for each Medicare-covered one-way trip via ground ambulance.    You have been asked to pay a $280 copayment for the emergency ambulance services. This service falls within the Ambulance 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 copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided April 27, 2021.   Your complaint about potentially being provided misinformation by a member services representive 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on July 12, 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 medical services provided to the enrollee on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a domiciliary or rest home visit with a physician (99334) provided on July 17, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for a domiciliary or rest home visit with a physician. You say that the rendering physician is a hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the Plan. You also ask us not to penalize the physician for the hospital staff's failure in taking the proper steps to obtain authorization for these services. The Plan denied your request. The Plan says the claim was denied for failure to obtain the required prior authorization and the requested medical records were not received.  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 a domiciliary or rest home visit with a physician (99334) provided on July 17, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for hearing aids (V5261) provided on May 7, 2021.  You asked the Plan to pay an additional amount for hearing aids. You say that your Plan covers up to $2,000 for hearing aids. You also say that you paid all but the $2,000 and the Plan should pay the remaining amount to the hearing aid provider. The Plan denied your request. The Plan says the provider was issued the total allowed amount for this service. The Plan also says that the maximum benefit has been exhausted.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays up to a $2,000 allowance for hearing aids every 3 years.        We looked at the file and the Plan's rules. The records show that the Plan paid $1,600 for the dispensing fee of the hearing aids (V5160), $400 for the fitting/orientation/checking of the hearing aids (V5011) and $53.13 for the assessment for the hearing aid (V5010).  The records also show the Plan paid the provider a total of $2,053.13 for your services at issue. The maximum allowed benefit has been exhausted and the remaining balance is your responsibility. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay an additional amount for hearing aids (V5261) provided on May 7, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that the enrollee is in the hospital and needs to go to a SNF where they are equipped to take care of her in her current state. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been 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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, was not hypoxic, and remained asymptomatic from a coronavirus infection. The enrollee received physical therapy and occupational therapy. The enrollee was at a maximal assist level with functional mobility. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 4, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the provider advised you that there would not be a copayment. The Plan denied your request. The Plan says you have been charged 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 $25 copayment for each specialist visit.   You have been asked to pay a $25 copayment for the specialist office visit. Specialist office visits fall 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 a specialist office visit provided on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (82728, 83540, 83550, 84100) provided  May 24, 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 codes billed are not separately payable.  The Plan must follow Medicare rules. Medicare rules say that laboratory services furnished to individuals for the treatment of End-Stage Renal Disease (ESRD) are included in the ESRD PPS as Part B services and are not paid separately.       We looked at the file and Medicare rules. The lab services at issue are dialysis related and are not separately payable. 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 (82728, 83540, 83550, 84100) provided May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the critical care services rendered on February 25, 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. The rules say that claims must be billed with the most precise diagnosis code.    We looked at the file and Medicare rules. The file shows that the services were not billed with a valid primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services rendered on February 25, 2021.