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

We decided that the Plan does not have to waive the copayment for inpatient hospital care from July 10, 2019 through July 21, 2019. You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on July 10, 2019 and discharged on July 21, 2019. You were asked to pay a $225 copayment per day from July 10, 2019 through July 17, 2019, days 1-8 of your inpatient stay. You were asked to pay a $113 copayment for day 9 of your inpatient hospital care, July 18, 2019. There were no copayment charges from July 19, 2019, day 10 of your inpatient hospital care until your day of discharge July 21, 2019. Per your contract there is a $225 copayment per day for days 1-8 and $113 copayment for day 9 for inpatient hospital care. 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 inpatient hospital care from July 10, 2019 through July 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve outpatient surgery services. You say that previous treatment with this provider gave you relief for more than 8 years. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided 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 a specialist office visit provided on October 16, 2019.
You asked the Plan to waive the copayment for a specialist office visit. You say that you gave your provider the incorrect insurance card. The Plan denied your request. The Plan says this service processed 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 services. You have been asked to pay a $45 copayment for a specialist office visit. 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 October 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora chest x-ray (71045) provided on November 20, 2019.You asked the Plan to pay forthe chest x-ray. You say that you would like reconsideration because this claim was denied as a duplicate in error.The Plan denied your request. The Plan says services that are considered column II procedures to another service are not eligible for reimbursement when billed with the column I procedure code.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the chest x-ray has a bundled relationship with code 32555 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay fora chest x-ray (71045) provided on November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames and lenses (V2020, V2206 and V2750)
provided on July 17, 2019.
You asked the Plan to pay for the eyeglass frames and lenses. You say that you would like reconsideration
because you were informed that this service was covered. The Plan denied your request. The Plan says this
benefit has been applied correctly as the Plan allows a $150 benefit towards the purchase of eyewear.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers a $150 allowance per calendar year.
We looked at the file and the Plan's rules. Per Plan rules, the Plan covered $150 towards your vision benefit.
You are responsible for the remaining balance for these services. Based on this information, we decided that
the Plan's rules for coverage of the eyeglass frames and lenses have not been met. Therefore, we decided that
the Plan does not have to pay for eyeglass frames and lenses (V2020, V2206 and V2750) provided on July 17,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on August 22, 2019. You asked the Plan to pay for the dental services. You say that the dental office advised the provider did not opt out of Medicare until January 1, 2020. The Plan denied your request. The Plan says payment is not able to be made for services provided by a dentist that has opted out of Medicare. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider in this case has opted out of the Medicare program. The file shows that the provider has entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveroot canal retreatment for the enrolllee.You asked the Planto pre-approvethe dental services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis 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 itemsor services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approveroot canal retreatment for the enrolllee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical multiple post collar to be provided by an out of network provider.
You asked the Plan to pre-approve a cervical multiple post collar. You say that you are the preferred vendor for the enrollee's physician office. The Plan denied your request. The Plan says the cervical multiple post collar can be provided by an in-network provider. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve a cervical multiple post collar to be provided by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 15, 2019 to October 16, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that this should covered. The Plan denied your request. The Plan says inpatient care was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. He was to be admitted to telemetry with an exacerbation of chronic obstructive pulmonary disease and uncontrolled diabetes but he left against medical advice. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided October 15, 2019 to October 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mohs surgery to be provided by an out of network (OON) provider.You asked the Plan to pre-approve Mohs surgery. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve Mohs surgery to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the debridement services rendered to you
on October 9, 2019 to November 6, 2019.
You asked the Plan to waive the copayments for these services. You say that you were never at the hospital and
were not told you were outpatient. The Plan denied your request. The Plan says the copayments were 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 $200
copayment for each Medicare-covered outpatient hospital services.
Review of the file shows that you received debridement services at an outpatient hospital clinic on October 9,
2019; October 16, 2019; October 23, 2019; and November 6, 2019. You have been asked to pay a $200
copayment per date of service for these services, for a total of $800. These services fall within the Medicarecovered
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 waive the copayments for
the debridement services rendered to you on October 9, 2019 to November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing services rendered from October 1,
2019 to October 28, 2019.
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 claim was 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 procedure code G0299 was billed with POS code 32
for a nursing facility. Code G0299 does not match this POS code and a corrected claim must be submitted.
Therefore, we decided that the Plan does not have to pay for the direct skilled nursing services rendered from
October 1, 2019 to October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis, bitewings provided on December 5, 2019.You asked the Plan to pay forthe periodic oral evaluation,prophylaxis, bitewings. You say that you realize this provider has not participated in Medicare. You also say that you have seen this provider for years and have always been partially reimbursed.The Plan denied your request. The Plan says this provider had opted out of Medicare prior to this date of service. The Plan also says that they are unable to make payments for services provided by a dentist who has opted out of Medicare under the enrollee's plan.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis, bitewings provided on December 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial as you should not be responsible for the inpatient copayment. The Plan denied your request. The Plan
says that the copayment has been applied correctly to the inpatient hospital care 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
$425 copayment for inpatient hospital care per admission.
You have been asked to pay a $425 copayment for the inpatient hospital admission. 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 November 21, 2019 to November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient observation services provided on February 3, 2020. You asked the Plan to waive the copayment for the outpatient observation services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient hospital observation services on the date of service at issue in this appeal. The Plan says the correct copayment has applied per your contract with the Plan. 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 $250 copayment for Outpatient hospital observation. We looked at the file, the Plan's contract and Medicare rules. The file shows you received outpatient observation services on February 3, 2020. You have been asked to pay a $250 copayment for the outpatient observation services. The outpatient observation services fall within the Outpatient hospital observation 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 outpatient observation services provided on February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetranscutaneous electrical nerve stimulation (TENS) therapy.You asked the Plan to pre-approvethese services. You say that you previously used the TENS and it worked well.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that TENS is not covered for acute pain.We looked at the file and Medicare rules. The file shows that you are requesting the TENS therapy for acute shoulder pain. The TENS is not covered for this condition.Therefore, we decided that the Plan does not have to pre-approvetranscutaneous electrical nerve stimulation (TENS) therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve the OON services. You say that the plan does not offer the service that the
requested provider is offering. The Plan denied your request. The Plan says there are specialists in-network
who can evaluate your condition.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide services for your medical condition. We found no exception that would require the
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve
medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup battery for a CPAP.
You asked the Plan to pre-approve a backup battery. The Plan denied your request. The Plan says that this is
not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a backup battery for a CPAP.
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 SNF services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met and you do not have a physician's order for SNF services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. There is insufficient medical records and physician support for admission to a SNF facility. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency transportation provided on April 13, 2019.You asked the Plan to pay for the non-emergency transportation. You say that you were advised your family could not drive you home because of the lack of medical personnel and equipment. You also say that you and your family chose a medical transport vehicle to take you home.The Plan denied your request. The Plan says the non-emergent transportation service was not plan-directed. The Plan also says that the provider used in this case is not contracted with Medicare.The Plan must follow Medicare rules. The rules say that Medicare does not pay for non-ambulance vehicle transport services. The services you have asked the Plan to pay for are non-ambulance vehicle transport services.Therefore, we decided that the Plan does not have to pay for the non-emergency transportation provided on April 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).You asked the Plan to pre-approve the core buildup. You say that the enrollee has recurrent decay and irreversible pulpitis. You also say that the enrollee is in pain.The Plan denied your request. The Plan says this service is not listed and is not covered under the enrollee's health 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 pre-approve a core buildup, including any pins when required (D2950).