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

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your medical needs are being met in the current acute setting.  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. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services. 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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the unlisted ambulance service (A0999) and routine disposable supplies (A0398) provided on November 15, 2020.  You asked the Plan to pay for the unlisted ambulance service and routine disposable supplies. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the billed services are considered incidental to the primary transportation services.  The Plan must follow Medicare rules. Medicare rules say that payment for items and services is included in the fee schedule payment.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the unlisted ambulance service and routine disposable supplies have not been met.  Specifically, CPT codes A0999 and A0398 are considered to the primary ambulance services which have been processed and paid by the Plan. Therefore, we decided that the Plan does not have to pay for the unlisted ambulance service (A0999) and routine disposable supplies (A0398) provided on November 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable home ventilator.  

You asked the Plan to pre-approve a portable home ventilator. You say that the services 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 ventilators (E0465, E0466, and E0467) are covered under specific conditions.  

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 portable home ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found a conclusory statement is insufficient to establish the medical need of the requested service. The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The elements of the coverage criteria 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 a portable home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on June 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 services provided to the enrollee on June 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic mammography, including CAD when performed
(77066) diagnostic digital breast tomosynthesis (G0279) provided August 5, 2021.

You asked the Plan to pay for the diagnostic service. You say that this was your regular preventative
mammogram. You are not going to be responsible for paying this as you are entitled to 1 free mammogram per
year and as far as you knew this was it. The Plan denied your request. The Plan says the claim was correctly
processed and applied towards the deductible per the Evidence of Coverage

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 $1,250 deductible. You will pay $10 copayment after the deductible is
met for each basic imaging service which applies to Outpatient diagnostic tests and therapeutic services and
supplies.

The item or service you asked the Plan to pay for falls within the benefit category Outpatient diagnostic tests
and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the
contract that there is $1,250 deductible which applies to Outpatient diagnostic tests and therapeutic services
and supplies. This cost sharing is a contractual obligation that had not been met at the time the diagnostic
service was received on August 5, 2021. Therefore, we decided that the Plan does not have to pay for
diagnostic mammography, including CAD when performed (77066) diagnostic digital breast tomosynthesis
(G0279) provided August 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergency wheelchair van transportation (A0130) provided on August 13, 2021.

You asked the Plan to waive the copayment for the non-emergency transportation. You say that you were not given the option to try and find a less expensive form of transportation for the enrollee and feel they should not be responsible for this cost. The Plan denied your request. The Plan says this claim was processed correctly, and the cost-sharing was assessed in accordance with the Plan's contract. Ambulance services require a $200 copayment for each one-way trip. The allowed cost of the service in this case was less than the full copayment, so the enrollee is being asked to pay $133.62.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for ambulance services. 

The enrollee has been asked to pay a $133.62 for the non-emergency transportation. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the non-emergency wheelchair van transportation (A0130) provided on August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection of a non-compounded foam sclerosant with ultrasound compression maneuvers, inclusive of all imaging guidance and monitoring (36465) rendered by the out-of-network (OON) provider on August 24, 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.

The provider in this case is 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 injection of a non-compounded foam sclerosant with ultrasound compression maneuvers, inclusive of all imaging guidance and monitoring (36465) rendered by the out-of-network (OON) provider on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composites provided from September 1, 2021, to September 15, 2021.  

You asked the Plan to pay for the resin-based composites. You say that you need help paying for these bills. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan also says that you did not enroll in or purchase the enhanced dental and vision package.  

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. The contract says the Plan offers optional supplemental benefits that you can buy for an additional premium, but you did not purchase this optional plan. Therefore, we decided that the Plan does not have to pay for the resin-based composites provided from September 1, 2021, to September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), scaling and root planing (D4341 x 3), 2D oral photographic image (D0350), complete series x-ray (D0210), comprehensive periodontal evaluation (d0180), scaling and root planing (D4342 x 2), and occlusal adjustment (D9951) provided from June 14, 2021, to July 13, 2021.

You asked the Plan to pay for the dental services. You say that the initial services you received were emergent. You say that the plan recommended an in network provider. You say that they were not open on the day you needed them and thus were not available. You also say that since you began treatment with this provider, you were not able to switch to someone else until treatment was completed. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made for services performed by a provider that has opted out of Medicare. The Plan also says that the services performed were not urgent or emergent.

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, dental services performed by a dentist that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), scaling and root planing (D4341 x 3), 2D oral photographic image (D0350), complete series x-ray (D0210), comprehensive periodontal evaluation (d0180), scaling and root planing (D4342 x 2), and occlusal adjustment (D9951) provided from June 14, 2021, to July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the recement or rebond of crown (D2920) provided on
August 25, 2021.

You asked the Plan to pay for the dental service. You say that your crown became unattached. You also say
that this should be a covered expense. The Plan denied your request. The Plan says the recement or rebond of
crown is not listed as a covered service.

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 recement or rebond of crown is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
recement or rebond of crown (D2920) provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric diagnosis interview examination (90792) provided on April 30, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the psychiatric services. You say that the services provided were medically necessary and were provided to the enrollee at the long-term care facility that he resides. 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 psychiatric diagnosis interview examination (90792) provided on April 30, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on May 15, 2021, to July 1, 2021.

You asked the Plan to waive the copayment for physical therapy. You say that you do not feel like you should have to pay for this because you were in constant pain. The Plan denied your request. The Plan says the correct copayments have been applied.

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 $20 copayment for outpatient rehabilitation services/in-network. 

You have been asked to pay a $20 copayment for physical therapy. The total amount you are being asked to pay is $240 ($20 x 12 visits = $240). Physical therapy falls within the outpatient rehabilitation services/in-network. 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 physical therapy provided by a participating provider on May 15, 2021, to July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for a shingles vaccine provided on July 27, 2021.

You asked the Plan to pay for this vaccine. You say that your doctor recommended this vaccine during your wellness exam. The Plan denied your request. The Plan says payment for this vaccine should be submitted to your Medicare Part D carrier.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this vaccine. The Plan follows the same rules. This vaccine was provided as a preventative service. Therefore, we decided that the Plan does not have to pay for a shingles vaccine provided on July 27, 2021 under Medicare Part B.

Benefits for this vaccine 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and 
services provided from August 7, 2021, to August 13, 2021.

You asked the Plan to waive the copayment for the inpatient stay. You say that you were dissatisfied with the 
care provided at the hospital and feel you should not be responsible for this cost. The Plan denied your request. 
The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your 
contract.

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 $295 
copayment for each of the first six days of an inpatient hospital stay. There is a $0 copayment for days 7-90.

You have been asked to pay a $1,770 copayment for the six-day inpatient stay ($295 x 6 = $1,770). 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 from August 
7, 2021, to August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) provided on 
July 16, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered as you did not see a specialist. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided.

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 Physician/Practitioner services, including doctor's office visits. 

You have been asked to pay a $50 copayment for a specialist office visit. The record indicates that you were 
seen by providers in a specialist's hematology and oncology office. 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 (99213) provided on July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for established patient domiciliary or rest home visit (99336) Prolonged physician services (99354) provided June 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the services provided were medically necessary and was provided to the enrollee at the long-term care facility that he resides. 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 established patient domiciliary or rest home visit (99336) Prolonged physician services (99354) provided June 25, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on July 6, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the nursing facility care. You say that you are requesting review and reconsideration for payment of this claim for acute visits to the nursing home. 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 subsequent nursing facility care (99309) provided on July 6, 2021 by an out-of-network (OON) provider.