Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the pressure-reducing air mattress.

You asked the Plan to waive the coinsurance for the pressure-reducing air mattress. You say that the billing is not appropriate. You say that you did not use the air mattress and you will not pay this invoice. The Plan denied your request. The Plan says the coinsurance 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 20% of the Medicare-allowed amount for durable medical equipment.

You have been asked to pay $29.44, which is less than the standard 20% coinsurance for the pressure-reducing air mattress. The pressure-reducing air mattress falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the pressure-reducing air mattress.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pickleball club membership fees (A9270).

You asked the Plan to pay for the membership fees. You say that your labs are the best they have been in 10 years since you started playing pickleball. It's keeping you in shape and paying off. The Plan denied your request. The Plan says membership fees for sports activities are not covered under the benefit.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits to a qualified health club or fitness facility.

The Plan's rules for coverage of gym benefits have not been met because This benefit does not cover membership fees to non-qualified health club or fitness facility. Therefore, we decided that the Plan does not have to pay for pickleball club membership fees (A9270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the rowing machine provided on September 5, 2020.
You asked the Plan to pay for the rowing machine. You say that the start date for reimbursement is not fair. The Plan denied your request. The Plan says purchases made prior to October 1, 2020, do not qualify.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the rules. The Plan benefits show that due to the Covid-19 pandemic, you can use your wellness allowance towards the purchase of exercise equipment. The effective date for this change is October 1, 2020, to December 31, 2020. Only purchases made during this period and submitted for reimbursement by the deadline will be reimbursed. Purchases made prior to October 1, 2020, do not qualify. The Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the rowing machine provided on September 5, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fitness equipment you received on September 2, 2020.
You asked the Plan to pay for the fitness equipment. The Plan denied your request. The Plan says this is not a covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan reimburses you up to $150 each calendar year towards your cost for membership in a qualified health club or fitness facility, covered instructional fitness classes, participation in wellness programs. The Plan's rules for coverage of gym benefits have not been met because the Plan's supplemental benefit does not covered fitness equipment. While the Plan did offer a temporary COVID-19 wellness allowance benefit that extended to fitness equipment, this temporary benefit began on October 1, 2020. The requested equipment was purchased prior to the temporary benefit allowance. Therefore, we decided that the Plan does not have to pay for the fitness equipment you received on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation provided on November 18, 2020.
You asked the Plan to pay for the consultation. You say that you were told by the Plan that this service would be covered. The Plan denied your request. The Plan says this service is not covered.
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 consultation provided on November 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on February 6, 2020.
You asked the Plan to pay for dental services. You say that your provider is listed as in-network on the Plan website. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered when performed by an out-of-network dentist.
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 when obtained from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for dental services provided by an out-of-network provider on February 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that SNF care is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating household distances. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and topical application of fluoride varnish provided on November 2, 2020.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and topical application of fluoride varnish. You say that these services are listed as being covered twice per year by the Plan. You also say that you were misinformed about your benefits. The Plan denied your request. The Plan says your annual allowance benefit had been exhausted. The Plan also says that when you contacted the Plan on October 26, 2020 you were made aware that your annual allowance was maxed out prior to this November 2, 2020 date of 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 Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on October 8, 2020 and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and topical application of fluoride varnish provided on November 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on October 27, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that you did not know this would be a diagnostic procedure. You say that you are screened more often and were surprised to receive a copayment. The Plan denied your request. The Plan says the copayment 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 $250 per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that a polyp was removed which is considered a surgical procedure. 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 colonoscopy provided on October 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes U0003 and G2024 are not supported.

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, the CPT Code Manual definition of code is G2024 is specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]) from an individual in a snf or by a laboratory on behalf of a hha, any specimen source. The definition of code U0003 is infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, making use of high throughput technologies as described by cms-2020-01-r.

We find that CPT cods U0003 and G2024 are not supported in the medical record. Specifically, there are no submitted laboratory results for the billed date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for enteral nutrition supplies (B4035, B0002, B4150, E0776) provided on May 1, 2020, through May 31, 2020.
You asked the Plan to pay for the enteral nutrition supplies. You say that you would like reconsideration because facilities are allowed to bill enteral supplies to the insurance company. The Plan denied your request. The Plan says that
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not forwarded sufficient information to substantiate their denial. The documentation submitted does not include an explanation as to why these services were denied, whether the member was in a Part A covered stay or if the billing provider is a durable medical equipment supplier. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated, and we must find in your favor. Therefore, we decided that the Plan has to pay for enteral nutrition supplies (B4035, B0002, B4150, E0776) provided on May 1, 2020, through May 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fitness equipment you received on September 5, 2020.
You asked the Plan to pay for the fitness equipment. The Plan denied your request. The Plan says this is not a covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan reimburses you up to $300 each calendar year towards your cost for membership in a qualified health club or fitness facility, covered instructional fitness classes, participation in wellness programs. The Plan's rules for coverage of gym benefits have not been met because the Plan's supplemental benefit does not covered fitness equipment. While the Plan did offer a temporary COVID-19 wellness allowance benefit that extended to fitness equipment, this temporary benefit began on October 1, 2020. The requested equipment was purchased prior to the temporary allowance benefit. Therefore, we decided that the Plan does not have to pay for the fitness equipment you received on September 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating provider on November 11, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that there was a provider referral for this CT scan. The Plan denied your request. The Plan says the correct copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for outpatient diagnostic tests/in-network/CT scans. The enrollee has been asked to pay a $200 copayment for a CT scan. The correct copayment has been applied to the CT scan that was provided. A CT scan falls within the outpatient diagnostic tests/in-network/CT scans benefit category. 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 a CT scan provided by a participating provider on November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye examination and evaluation, with initiation or continuation of diagnostic and treatment program and Determination of refractive state (92014, 92015).

You asked the Plan to waive the copayment for the vision services. You say that you did not know you were referred to a specialist with a higher copayment. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye.

You have been asked to pay a $40 copayment for the vision services. This service falls within the Vision 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 the eye examination and evaluation, with initiation or continuation of diagnostic and treatment program and Determination of refractive state (92014, 92015).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided by a participating provider on October 9, 2020.
You asked the Plan to waive the copayment for podiatry services. You say that you thought these copayments would be waived. The Plan denied your request. The Plan says the correct copayment 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 $15 copayment for podiatry services/in-network. You have been asked to pay a $15 copayment for podiatry services. Podiatry services fall within the podiatry 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 podiatry services provided by a participating provider on October 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350 x 4).

You asked the Plan to pay for the dental services. You say that you went in for a regular teeth cleaning. You say that you were told you needed a deep cleaning. You say that you told the dentist that your insurance would only cover a regular cleaning. You also say that you did not authorize any other services other than what your insurance would cover. The Plan denied your request. The Plan says 2D oral or facial photographic image is not listed as a covered service. The Plan also says that you did not call to verify your benefits prior to the date of 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 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 2D oral or facial photographic image (D0350 x 4).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for a diagnostic or therapeutic nerve blocks (01992) provided on August 11, 2020.
You asked the Plan to pay for anesthesia. You say that this was medically necessary. The Plan denied your request. The Plan says anesthesia was not necessary for this procedure.
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 pay for anesthesia. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no indication for sedation during a nerve block. The sedation provided was 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 anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for a diagnostic or therapeutic nerve blocks (01992) provided on August 11, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for emergency care services provided on August 19, 2020.
You asked the Plan to pay for emergency care. You say that the enrollee could not swallow or eat. The Plan
denied your request. The Plan says that the denial of payment for these services is correct, because this
provider is out-of-network with the Plan and authorization was not obtained.
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of
immediate medical attention would result in serious jeopardy to their health.
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with
an average knowledge of medicine would reasonably expect the absence of immediate medical care to
seriously jeopardize their health in this case. Furthermore, the enrollee was outside of the Plan's service area at
the time of service, so the enrollee was unable to obtain service from an in-network provider. Therefore, we
decided that the Plan has to pay for emergency care services provided on August 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Prolia.
You asked the Plan to pre-approve Prolia. You say that the enrollee cannot take oral or intravenous bisphosphonates. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Reclast, Fosamax, or a combination of oral and intravenous bisphosphonates for at least 24 months before it will approve Prolia.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Reclast, Fosamax, or a combination of oral and intravenous bisphosphonates. Based on the records provided the enrollee does have gastroesophageal reflux which is a concern for adverse effects with oral bisphosphonates. However, there is no indication that Reclast would likely be less effective and/or have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia.