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

We decided that the Plan does not have to waive the copayment for the telehealth visit facility fee provided on
December 3, 2020.

You asked the Plan to waive the copayment for the telehealth visit facility fee. You say that the visit was over
the phone and you paid your $50 copayment. You say that you shouldn't be billed a facility fee when you never
entered the facility. 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 a $325
copayment for each in-network, Medicare-covered outpatient hospital visit.

You have been asked to pay $26.65, which is less than the standard $325 copayment for the telehealth visit
facility fee. The telehealth visit facility fee falls within the "Outpatient hospital services" benefit category. A
facility fee still applies to telehealth visits. 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
telehealth visit facility fee provided on December 3, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve right breast augmentation.

You asked the Plan to pre-approve right breast augmentation. You say that you would like reconsideration because the requested procedure is medically necessary. The Plan denied your request. The Plan says that the requested service is not a Medicare covered benefit.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

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 right breast augmentation. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the reconstruction being performed on the right breast follows a medically necessary mastectomy and is therefore, by rule, not cosmetic.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of right breast augmentation have been met. Therefore, we decided that the Plan has to pre-approve right breast augmentation.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided from August 17, 2020, to September 24, 2020.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree with the charges because the services were necessary due to a surgical procedure. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services from August 17, 2020, to September 24, 2020, for a total of 12 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x 12 (visit) = $480. You have been asked to pay the total copayment amount of $480 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayment for outpatient rehabilitation services provided from August 17, 2020, to September 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam image capture (D0367) provided on February 26, 2020 and the dental re-evaluation (D0171) provided on September 15, 2020.
You asked the Plan to pay for the cone beam image capture and re-evaluation. You say that these services were necessary, and you do not understand why they were denied. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone beam image capture (D0367) provided on February 26, 2020 and the dental re-evaluation (D0171) provided on September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider on October 14, 2020.

You asked the Plan to pay for the nursing facility care. You say that the physician depends on the hospital staff to verify eligibility and obtain proper authorization. You say that the physician provided medically necessary services and should be reimbursed. The Plan denied your request. The Plan says prior authorization was required but not obtained.

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 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 nursing facility care provided by an out-of-network provider on October 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bavencio (J9023).

You asked the Plan to pre-approve Bavencio. You say that the drug is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Bavencio. Our reviewer says that Bavencio is not medically necessary. Our physician reviewer found the patient has new lung nodules which would not be considered pseudoprogression since they are new sites of disease. This would be considered progression. Based on this information, coverage criteria for Bavencio is not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Bavencio have not been met. Therefore, we decided that the Plan does not have to pre-approve Bavencio (J9023).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered pressure reducing air mattress.

You asked the Plan to pre-approve a powered pressure reducing air mattress. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that a group 2 support surface is covered when specific criteria is met.

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 a powered pressure reducing air mattress. Our reviewer says that the item is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the coverage criteria. The provided medical records do not document that the enrollee has multiple stage II pressure ulcers located on the trunk or pelvis which have failed to improve over the past month, during which time the enrollee has been on a comprehensive ulcer treatment program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a powered pressure reducing air mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure reducing air mattress.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested services are medically necessary for the enrollee. The Plan denied your request. The Plan says rules for the LTACH services have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was admitted to the current acute care hospital with worsening bullous pemphigoid, cellulitis, and septic shock requiring vasopressors, antibiotics, and steroids. Recent notes show the enrollee has worsening kidney failure, uncontrolled diabetes, and worsening leukocytosis. The enrollee appears to be unstable with worsening condition requiring additional short-term acute care services to complete treatment and stabilize that can safely be completed at the current facility. The enrollee does not require services at the LTACH that are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 a semi-electric hospital bed. Our reviewer says that the item is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that a semi-electric hospital bed is medically necessary for this 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 a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the periodontal maintenance (D4910) provided on November 16, 2020.
You asked the Plan to waive the deductible for the periodontal maintenance. You say that you did not have to pay a deductible for this service in 2019, and do not feel you should have to pay one now. The Plan denied your request. The Plan says there is a $75 deductible for comprehensive dental services in the 2020 Plan year. Plan benefits and cost-sharing are subject to change from year to year.
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 $75 deductible for comprehensive dental services in 2020. The item or service you asked the Plan to waive the deductible for falls within the comprehensive dental services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $75 deductible for comprehensive dental services. This cost sharing is a contractual obligation that had not been met at the time the periodontal maintenance was received on November 16, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the periodontal maintenance (D4910) provided on November 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care, per day, for the evaluation and management of a patient (99232) provided October 13, 2020.
You asked the Plan to pay for the subsequent hospital care. You say that reprocess your claim based on the appropriate geographic area and CMS payment methodology based on the enrollee's date of service. The Plan denied your request. The Plan says the claim was processed correctly as an out of network provider and payment was applied towards the enrollee's annual deductible.
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 $1000 annual deductible. The item or service you asked the Plan to pay for falls within the benefit category Inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 annual deductible. This is the amount that the enrollee must pay prior to the plan paying their share for covered services. The enrollee has paid $491.60 towards the annual deductible. This cost sharing is a contractual obligation that had not been met at the time the subsequent hospital care was received on October 13, 2020. Therefore, we decided that the Plan does not have to pay for subsequent hospital care, per day, for the evaluation and management of a patient (99232) provided October 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a participating provider on September 18, 2020.
You asked the Plan to waive the copayment for outpatient hospital services. You say that this is a financial hardship, and you cannot afford this. 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 $350 copayment for outpatient hospital services/outpatient services. You have been asked to pay a $350 copayment for outpatient hospital services. The correct copayment has been applied to the services that were provided. Outpatient hospital services fall within the outpatient hospital services/outpatient 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 copayment for outpatient hospital services provided by a participating provider on September 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of the skin substitute (15275) provided on September 23, 2020.
You asked the Plan to pay for the application of the skin substitute. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says skin substitute application procedures must be billed with a skin substitute product.
The Plan must follow Medicare rules. Medicare rules say that the submission of certain skin substitute application procedures requires the reporting of a skin substitute product for the same day. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the application of the skin substitute have not been met. Specifically, this claim for skin substitute application does not include the required skin application substitute product. Therefore, we decided that the Plan does not have to pay for the application of the skin substitute (15275) provided on September 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
November 30, 2020, through December 1, 2020.
You asked the Plan to pay for the acute inpatient hospital care. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the inpatient hospital admission 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 the 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 that Medicare rules state that the decision to admit as an inpatient should generally be based on the treating physician's reasonable expectation of a length of stay spanning two or more midnights, taking into account complex medical factors that must be documented in the medical record. Because this is based upon the physician's expectation, as opposed to a retroactive determination based on the actual length of stay, unforeseen circumstances that result in a shorter stay than the physician's reasonable expectation may still result in a hospitalization that is appropriately considered inpatient. In this case, the documentation at the time of the admission does not reflect an expectation based upon medical considerations that the hospital stay would span two or more midnights. The elements of the coverage rule are not satisfied.
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 not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 30, 2020, through December 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81238) provided on September 22, 2020.
You asked the Plan to pay for a hereditary cardiovascular screening. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular screening (81238) provided on September 22, 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 9, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you had to get a second scan because the first one was unusable. You say that you should not have to pay for this twice. 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 $150 copayment for outpatient diagnostic tests/CT scans. You have been asked to pay $131.37 which is less than your copayment amount of $150 for a CT scan. Since a CT scan was provided to you, the correct copayment has been applied. A CT scan falls within the outpatient diagnostic tests/CT scans benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan provided by a participating provider on November 9, 2020.
We note your complaint about having to get a second scan because the first one was unusable Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.