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

We decided that the Plan does not have to adjust the cost share for the services you received from April 20, 2021, to April 21, 2021.
You asked the Plan to adjust the cost share. You say that you should have to pay the inpatient cost share. The Plan denied your request. The Plan says you were provided outpatient services.
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% coinsurance for outpatient hospital services. Review of the file shows that you were provided outpatient hospital services on April 20, 2021, and April 21, 2021. You were not admitted as an inpatient during this stay. You have been asked to pay a 20% coinsurance for the services. The services fall within the outpatient hospital 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 adjust the cost share for the services you received from April 20, 2021, to April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prometheus IBD sgi Diagnostic testing.

You asked the Plan to pre-approve 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 the Prometheus IBD sgi Diagnostic test is non-covered. 

We looked at the file and Medicare rules. The requested test is the Prometheus IBD sgi Diagnostic test. This test is non-covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve Prometheus IBD sgi Diagnostic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on March 22, 2021.
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you were unable to get an appointment with a participating provider until September, so you kept the appointment with the non-participating provider. You say that you should receive a partial reimbursement. The Plan denied your request. The Plan says this provide is no longer a participating dental provide 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on March 22, 2021.
Appeal type: Home Health
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 (99347) provided on September 30, 2019.
You asked the Plan to pay for the home visit. You say that you believe this claim should be reprocessed for payment. The Plan denied your request. The Plan says the provided records do not support that a physician or non-physician practitioner were physically present. The Plan also says that the submitted code does not appropriately reflect the services provided by the licensed vocational nurse.
The Plan must follow Medicare rules. Medicare rules say that a home visit cannot be billed by a physician unless the physician was actually present in the beneficiary's home. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99347) provided on September 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on July 15, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is not eligible for payment.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on July 15, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept Procedure.
You asked the Plan to pre-approve Intracept Intraosseous Nerve Ablation system of the basivertebral nerve (BVN) (22899). You say that the enrollee has tried and failed conservative treatment for a long time, without relief. The Plan denied your request. The Plan says there is not enough evidence in the medical literature to suggest that the Intracept Procedure is an appropriate procedure for the enrollee's back pain
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 Intracept Intraosseous Nerve Ablation system of the basivertebral nerve (BVN) (22899). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure at this time. Therefore, the request is considered not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept Intraosseous Nerve Ablation system of the basivertebral nerve (BVN) (22899) have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept Procedure
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve Intracept. You say that this procedure is supported as safe and effective, and is medically necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that Intracept is helpful for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature showing the requested procedure to be an effective and/or safe treatment for the enrollee's condition. There is no compelling rationale or extenuating circumstance noted to support the necessity of this request as an exception to guidelines.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on February 4, 2021.
You asked the Plan to pay for the dental services. You say that the locators were placed on the dentures so they can stay fastened to the gums. You say that this was necessary for the dentures and the charges should be reconsidered. The Plan denied your request. The Plan says you were already reimbursed the full dental benefit of $575 for the services received on February 1, 2021.
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, you also have a maximum benefit of $575 for dental services every calendar year. The Plan paid for $575 toward the dental services received on February 1, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on February 4, 2021
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 17, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat elevator represented by code E2300. You asked the Plan to pre-approve the seat elevator. You say that the enrollee is a high fall risk for rehospitalization without proper durable medical equipment. The Plan denied your request. The Plan says a power seat elevation system is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The seat elevator in this appeal does not serve a purpose that is primarily medical in nature. Medicare rules clearly state that a power seat elevation feature is non-covered. Therefore, we decided that the Plan does not have to pre-approve a seat elevator represented by code E2300.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from February 3, 2021, to February 28, 2021.
You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with the charges because the provider did not request an extension with the Plan and now you are being charged. 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 $0 copayment for days 1-20 and a $184 copayment for days 21-100 for SNF care. The record shows that you had a SNF stay from February 3, 2021, to February 28, 2021. You are not being asked to pay a copayment for days 1-20 (February 3, 2021, to February 22, 2021). You are responsible to pay a $184 copayment for days 21-25 (February 23, 2021, to February 27, 2021). $184 (copayment) x 5 (SNF days) = $920. You have been asked to pay the total copayment amount of $920 for a SNF stay. A SNF stay falls within the SNF 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 a SNF stay provided from February 3, 2021, to February 28, 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 LTACH admission is medically necessary. The Plan denied your request. The Plan says all services that would be provided in the LTACH are being provided in the current acute care setting which is already approved. Therefore, the requested LTACH services are not medically necessary, reasonable, or appropriate for the diagnosis and condition of the member at this time.
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 that there is no documentation provided indicating medical necessity for the requested LTACH services. 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 she 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 waive the coinsurance for outpatient dialysis provided by a participating provider on February 4, 2021, to February 27, 2021.
You asked the Plan to waive the coinsurance for outpatient dialysis. You say that you have never had a payment for this. The Plan denied your request. The Plan says the correct coinsurance has 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% coinsurance for services to treat kidney disease/in-network/outpatient dialysis treatments. You have been asked to pay a 20% coinsurance of the allowed amount for outpatient dialysis. The total allowed amount per session is $649. The amount you owe per session is $129.80 ($649 x 20% = $129.80). The total amount you are being asked to pay is $1,298 ($129.80 x 10 sessions = $1,298). The correct coinsurance has been applied to the dialysis treatments that were provided. Outpatient dialysis falls within the services to treat kidney disease/in-network/outpatient dialysis treatments benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for outpatient dialysis provided by a participating provider on February 4, 2021, to February 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spinal x-ray you had on March 31, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that this x-ray was not performed at a hospital, so it should not have a copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $105 copayment for basic radiological services at an outpatient hospital facility. You have been asked to pay a $105 copayment for the x-ray.The records show that the facility where you had these services is considered an outpatient hospital facility. That is why the x-ray falls within the basic radiological services at an outpatient hospital facility 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 spinal x-ray you had on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473).
You asked the Plan to pre-approve the dental procedure. You say that this procedure is necessary for you to be fitted for dentures. The Plan denied your request. The Plan says this service is 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 pre-approve removal of torus mandibularis (D7473).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided form September 21, 2020, to October 17, 2020.
You asked the Plan to waive the copayment for a SNF stay. You say that you cannot afford the charges. 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 $0 copayment for days 1-20 and a $178 copayment for days 21-100 for SNF care. You had a SNF stay from September 21, 2020, to October 17, 2020. You are not being asked to pay a copayment for days 1-20 (September 21, 2020, to October 10, 2020). You are responsible to pay a $178 copayment for days 21-16 (October 11, 2020, to October 16, 2020). The total amount you owe is: $178 (copayment) x 6 (SNF days) = $1,068. You have been asked to pay the total copayment amount of $1,068 for a SNF stay. A SNF stay falls within the SNF 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 a SNF stay provided form September 21, 2020, to October 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 enrollee's medical conditions are stable and there are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. 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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had at an orthosurgeon's office on March 24, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you do not believe you should have to pay this copayment because the doctor brought students into the exam room with him without your knowledge. You also say that you had a visit on March 11, 2021, that was with the doctor's nurse practitioner. You said that if you had seen the doctor on that first visit, you would not have had two separate copayments. The Plan denied your request. The Plan says you were charged this copayment 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 $45 copayment for specialist visits. You have been asked to pay a $45 copayment for the office visit. The office visit falls within the specialist 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 the office visit you had at an orthosurgeon's office on March 24, 2021.
Your complaint about students being present during this visit as well as seeing the nurse practitioner prior to this visit. 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.