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

We decided that the Plan does not have to waive the cost share for the specialist office visits and the Part B drugs provided from January 29, 2020 to February 21, 2020. You asked the Plan to waive the cost share for the specialist office visits and the Part B drugs. You say that you were told that Medicare would pay for these procedures. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40 copayment for in-network physician specialist services and 20% coinsurance for all other in-network drugs covered under Medicare Part B. You have been asked to pay a total of $276.94 for the specialist office visits and the Part B drugs. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Part B drugs fall within the "Medicare Part B prescription drugs" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Copayment/Coinsurance
Member Liability
January 29, 2020
Specialist office visit
$61.85
$40.00
$40.00
February 5, 2020
Specialist office visit
$200.55
$40.00
$40.00
February 5, 2020
Part B injection
$392.37
20%
$78.47
February 21, 2020
Specialist office visit
$200.69
$40.00
$40.00
February 21, 2020
Part B injection
$392.37
20%
$78.47
Total
$276.94
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 cost share for the specialist office visits and the Part B drugs provided from January 29, 2020 to February 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on January 3,
2020 and January 10, 2020.
You asked the Plan to waive the copayment for the arthrocentesis. You say that you disagree with the
copayment. The Plan denied your request. The Plan says the copayments 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 per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital
outpatient facility.
You have been asked to pay a $200 copayment for each arthrocentesis. The total amount you owe is $400
($200/visit x 2 visits = $400). The arthrocentesis falls within the "Outpatient surgery, including services
provided at hospital outpatient facilities and ambulatory surgical centers" 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 arthrocentesis provided on January 3, 2020 and January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on March 21, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you do not feel like you should be charged a copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $50 copayment for each urgent care visit. You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The record shows you received services during the urgent care 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 the urgent care visit provided on March 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing provided on March 3, 2019.
You asked the Plan to pay for the testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the testing provided on March 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 4, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services. 
 
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 physician services provided on December 4, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic services (97016, 97032, 96372, 97112, 96372, J3490, J3475, J3415, J3411) provided in a chiropractic office on March 28, 2019.
You asked the Plan to pay for therapeutic services. You say that this should be covered. The Plan denied your request. The Plan says these services are not covered when provided in a chiropractic office.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for therapeutic services (97016, 97032, 96372, 97112, 96372, J3490, J3475, J3415, J3411) provided in a chiropractic office on March 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid assessment and hearing aids provided August
7, 2019 to August 15, 2019.
You asked the Plan to pay for the hearing services. You say that you received a bill for $1400 from the
provider and you cannot afford that. You thought that the plan would pay for the hearing aids. The Plan denied
your request. The Plan says this claim was 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 any
amount above the Plan's $500 benefit limit.
You have been asked to pay $900 for the hearing services. The services falls within the hearing 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 pay for the hearing aid assessment and hearing aids provided August 7,
2019 to August 15, 2019.
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 for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee can safely receive care in a less intensive setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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.The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met.Therefore,we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested outpatient diagnostic testing.
You asked the Plan to pre-approve the outpatient diagnostic testing. The Plan denied your request. The Plan
says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider,
which requires prior authorization from the plan.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the
requested outpatient diagnostic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for adjunctive prediagnostic (D0431) antimicrobial agents (D4381x3) gingival irrigation (D4921x2) and other drugs (D9630x3) provided January 10, 2020. 
 
You asked the Plan to pay for the dental services. You say that you do not fully understand all of the procedures or coding involved but you do know the outline of benefits from the Plan stated 100% coverage for all of the things that you were having done. The Plan denied your request. The Plan says these services are not covered under the plan benefits. 
 
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 adjunctive prediagnostic (D0431) antimicrobial agents (D4381x3) gingival irrigation (D4921x2) and other drugs (D9630x3) provided January 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 26, 2020.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered on February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve a stair lift. You say that you cannot go up and down the eighteen flights of stairs and have to be carried. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rosuvastatin Calcium 5mg Tablets.
You asked the Plan to pre-approve Rosuvastatin Calcium. You say that the medication is medically necessary. The Plan denied your request. The Plan says coverage for this drug is not available under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rosuvastatin Calcium 5mg Tablets.
Benefits for Rosuvastatin Calcium may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary. The Plan
denied your request. The Plan says you do not need an IRF level of care, there is alternative levels of care
available that would be more suitable.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 records do not indicate that there are significant, or complex medical/nursing
issues that could not be addressed at an alternate level of care. Ongoing pain medication and other medication
management, wound care, and daily therapy can be provided at an alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the requested drug is covered under your Part D plan. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.  
 
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.You asked the Plan to pre-approve SNF admission. The Plan denied your request. The Plan says SNF admission is not medically necessary.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.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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on February 20, 2020.You asked the Plan to pay forthese 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 these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an outpatient rehabilitation setting and should have been billed with POS code57.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the hospital outpatient clinic visit, the echocardiogram, and the laboratory work provided on September 2019 and September 27, 2019.
You asked the Plan to waive the cost share for the hospital outpatient clinic visit, the echocardiogram, and the laboratory work. You say that these bills create a financial hardship and you cannot afford the deductible cost. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $975 deductible that applies towards out-of-network outpatient hospital clinic visits and out-of-network echocardiograms, 30% coinsurance for diagnostic procedures and tests at an out-of-network outpatient hospital, and 30% coinsurance for laboratory services at an out-of-network outpatient hospital.
The out-of-network outpatient hospital clinic visit you asked the Plan to waive the cost share for falls within the "Outpatient hospital services" benefit category. The out-of-network echocardiogram and the out-of-network laboratory work fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $975 deductible that applies out-of-network outpatient hospital clinic visits and out-of-network echocardiograms, 30% coinsurance for diagnostic procedures and tests at an out-of-network outpatient hospital, and 30% coinsurance for laboratory services at an out-of-network outpatient hospital. See chart below.
Date of Service
Service
Allowed Amount
Deductible/
Coinsurance
Member Liability
September 20, 2019
Clinic visit
$125.04
$975
$125.04
September 27, 2019
Echocardiogram
$536.95
$975
$515.06 - This is where you met your deductible amount.
$21.89 - This is the remaining allowed amount ($536.95 - $515.06)
30%
$6.57
September 27, 2019
Laboratory work
$90.77
30%
$27.23
Total
$673.90
This cost sharing is a contractual obligation that had not been met at the time the hospital outpatient clinic visit, the echocardiogram, and the laboratory work were received on September 20, 2019 to September 27, 2019. Therefore, we decided that the Plan does not have to waive the cost share for the hospital outpatient clinic visit, the echocardiogram, and the laboratory work provided on September 2019 and September 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on March 31, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you did not go to the doctor this day and would like the claim removed from your account. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $35 copayment for each specialist visit. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were evaluated for an acute visit via telemedicine.
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 specialist office visit provided on March 31, 2020.