Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient hospital facility visits, the specialist services, and the urgent care visits provided from September 22, 2019 to October 25, 2019.
You asked the Plan to waive the copayments for the outpatient hospital facility visits, the specialist services, and the urgent care visits. You say that you feel you should not be responsible for these cost share amounts and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received specialist services in an outpatient hospital facility and urgent care visits on the dates of service at issue in this appeal. The Plan states the correct copayments have 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 $325 copayment for each Medicare-covered outpatient hospital visit, a $50 copayment for each Medicare-covered specialist office visit, and a $50 copayment per visit for Medicare-covered urgently needed services.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you had outpatient hospital facility services on October 9, 2019, October 18, 2019, and October 25, 2019. You have been asked to pay a $203.71 copayment for the outpatient hospital facility visits on October 9, 2019 and October 18, 2019, which is less than the contracted $325 copayment. You have been asked to pay a $133.75 copayment for the outpatient hospital facility visit on October 25, 2019, which is less than the contracted $325 copayment amount. The outpatient hospital facility visits fall within the Outpatient hospital services benefit category. The file shows you had services provided by a specialist on October 9, 2019 and October 25, 2019. You have been asked to pay a $50 copayment for the specialist visit on October 9, 2019 and a $23.36 copayment for the specialist visit on October 25, 2019, which is less than the contracted $50 copayment amount. The specialist visits fall within the Physician/Practitioner services benefit category. The file shows you received urgent care services on September 22, 2019, September 24, 2019, September 27, 2019, and October 6, 2019. You have been asked to pay a $50 copayment for each urgent care visit. The urgent care visits fall within the Urgently needed services benefit category. This means that you have been asked to pay the correct amounts 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 outpatient hospital facility visits, the specialist services, and the urgent care visits provided from September 22, 2019 to October 25, 2019.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
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 the enrollee is currently undergoing treatment at an acute care hospital for a renal rupture with abscess. The enrollee has drains in place and is receiving antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital until such time no acute services are required. 
 
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 pay for the medical services provided to you by an out-of-network provider on March 6, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on March 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME on January 2, 2020.
You asked the Plan to waive the coinsurance for the DME. 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 2020 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 show that you received the DME on January 2, 2020. You are asked to pay 20% coinsurance for the DME. 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 the DME on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 4, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 24, 2019, to December 26, 2019. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says that the services could have been provided under observation. 
 
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 the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the enrollee was a then 74-year-old female who presented to ED on December 24, 2019, with worsening cough, SOB and pleuritic CP. She was evaluated and diagnosed with acute bronchitis. Her condition stabilized and improved and she was discharged home when considered medically stable on December 26, 2019. The record showed 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. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from December 24, 2019, to December 26, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on November 20, 2019. 
 
You asked the Plan to pay for the prophylaxis. You say that you did not understand that you were exceeding the frequency limitation benefit. The Plan denied your request. The Plan says the benefits for this service have been satisfied and the frequency limitation had been exceeded. 
 
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, prophylaxis and is limited to two procedures per calendar year. The record shows that you received prophylaxes on April 3, 2019 and June 19, 2019 and your prophylaxis benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve resin-three surfaces, anterior teeth 6, 11 (D2332) resinbased composite, two surfaces, anterior teeth 7, 8 (D2331) provided December 31, 2019. 
 
You asked the Plan to pre-approve the dental services. You say that you was informed this procedure would cost $800 and you had to pay $400 upfront. The provider quoted you one amount and then billed the plan more. Now you're being told you still owe $569. The Plan denied your request. The Plan says the annual maximum has been exhausted. 
 
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 health plan contract specifically says after the annual maximum is exhausted, any remaining charges are your responsibility. 
 
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 resin-three surfaces, anterior teeth 6, 11 (D2332) resin-based composite, two surfaces, anterior teeth 7, 8 (D2331) provided December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related services provided on June 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the office visit and related services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON 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 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit and related services provided on June 24, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to reimburse you for the knee scooter purchased on December 17, 2019. 
 
You asked the Plan to pay for the knee scooter. You say that you were told by the Plan that you would be reimbursed 80% of the sale price. The Plan denied your request. Now the Plan has confirmed to MAXIMUS that you were told to use this provider and you would be reimbursed 80% for the knee scooter. 
 
The Plan must follow Medicare rules. Medicare rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
We looked at the file and Medicare rules. The record shows you were told what provider to use and that you would be reimbursed 80% of the sale price. Based on this information, we decided that Medicare rules for coverage of the knee scooter have been met. Therefore, we decided that the Plan has to reimburse you 80% for the knee scooter purchased on December 17, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 6, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent, non-urgent services with out-of-network providers require prior authorization.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on January 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve proton beam therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary, as conventional radiation therapy treatment would cause damage to your hearing, mind, and eyes. The Plan denied your request. The Plan says this is not considered a standard of care. 
 
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 the therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have declined surgery. The documentation does not indicate that you have had prior radiation to the area. The NCCN Guidelines Version 1.2020 page OR-A states that for definitive radiation of the oral cavity, either IMRT or 3D conformal radiation is recommended. On page MS-13 of those guidelines, it states it is premature to conclude that proton beam therapy has been established as superior to other modern radiation techniques such as IMRT, particularly with regard do tumor control. The documentation does not adequately demonstrate that Proton beam radiotherapy is considered the treatment of choice for you, and does not address the risk to normal tissue, the risk of disease recurrence, and the advantages of the treatment over IMRT or 3dimensional conformal radiation. Therefore proton beam therapy is not medically reasonable and 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 the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pulp vitality tests provided on November 13, 2019.You asked the Plan to pay forthe pulp vitality tests. You say that you had an infection in a molar bone, which required a special treatment.The Plan denied your request. The Plan says this service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the pulp vitality tests provided on November 13, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental implant services rendered on December 13, 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 services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental implant services rendered on December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Levo LCEV manual wheelchair and components.
You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says the power-standing feature is not medically necessary, or covered by Medicare.
The Plan follows Medicare rules. Medicare rules say that a power standing feature (E2301) is non-covered because they are not primarily medical in nature. 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 requested wheelchair. Our physician reviewer found that the Levo manual wheelchair is not medically necessary. This wheelchair contains a power standing feature (E2301) that is non-covered because it is not primarily medical in nature. The wheelchair with the included standing feature exceeds your medical needs. 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 requested wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Levo LCEV manual wheelchair and components.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Iron infusions (J1756) provided September 18 to September 27, 2019. 
 
You asked the Plan to waive the coinsurance for the Iron infusions. You say that you never had to pay a copayment before. The copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was 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 Part B drugs.  
 
You have been asked to pay a 20% coinsurance for the Iron infusions. The Iron infusions falls within the Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Iron infusions (J1756) provided September 18 to September 27, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the occupational therapy (OT) services rendered from March 13, 2019 to March 14, 2019.
You asked the Plan to waive the copayments for these services. You say that you believed you were inpatient so the copayments shouldn't apply. 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 $30 copayment, after the deductible for each specialist visit for Medicare-covered benefits.
Review of the file shows that you received outpatient OT services on March 13, 2019 and March 14, 2019. You have been asked to pay a $30 copayment per date of service for these services, for a total of $60. These services fall within the specialist visit for Medicare-covered benefits benefit category. The file shows that the services were provided by a physician and not an occupational therapist. 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 occupational therapy (OT) services rendered from March 13, 2019 to March 14, 2019.