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

We decided that the Plan does not have to waive the cost for the CPAP device and supplies provided on October 5, 2020.
You asked the Plan to waive the cost for the CPAP device and supplies. You say that you were not advised you would be on a trial, but you have been making payments. You say that you need this machine and are requesting the Plan to cover the cost. The Plan denied your request. The Plan says the cost share applied correctly.
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 4% coinsurance at an in or out-of-network durable medical equipment provider.
The item or service you asked the Plan to waive the cost for falls within the "Durable medical equipment
(DME) and related supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in
the contract that your $500 applies to durable medical equipment. This cost sharing is a contractual obligation
that had not been met at the time the CPAP device and supplies were received on October 5, 2020. Therefore
$174.92 has been applied to meet your deductible.
Since your deductible has been met you have also been asked to pay $11.32 for the supplies.
Service Allowed Amount Coinsurance Member Liability
Humidifier $17.53 4% $0.70
Tubing $33.69 4% $1.35
Filter $13.35 4% $0.53
Headgear $18.03 4% $0.72
Facemask $95.12 4% $3.80
Replacement Facemask $105.54 4% $4.22
TOTAL: $11.32
The total amount you owe is $186.24 ($174.92 deductible + $11.32 coinsurance = $186.24). 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 for the CPAP device and supplies provided on October 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on November 11, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this copayment. 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 $325 copayment for outpatient surgery/in-network/outpatient hospital facility. You have been asked to pay a $325 copayment for an outpatient surgery. The correct copayment has been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital facility 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 an outpatient surgery provided by a participating provider on November 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Herceptin and Perjeta provided on December 22, 2020.

You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says the drugs are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 pay for the drugs. Our reviewer says that Herceptin and Perjeta were not medically reasonable and necessary in this case. Our physician reviewer found that irrespective of HER2/neu status, Herceptin and Perjeta are not compendia or literature supported for pancreatic cancer. 

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 drugs have not been met. Therefore, we decided that the Plan does not have to pay for the Herceptin and Perjeta provided on December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral appliance you received on August 10, 2020.
You asked the Plan to pay for the oral appliance. The Plan denied your request. The Plan says this is not a covered benefit.
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 oral appliance you received on August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that this equipment is medically necessary. The
Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.

While a shower chair 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 shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the crown (D2790) provided on March 16, 2021 by an OON provider.

You asked the Plan to pay more for the crown. You say that you contacted the provider's office prior to receiving this service and were advised they were participating with your plan. The Plan denied your request. The Plan says you are responsible for the difference in the Plan's allowed amount and the dentist's submitted fee for services performed by a non-participating dentist. The Plan also says that you are responsible for the costs that exceed your calendar year plan maximum.

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, you are responsible for the difference between the OON provider's billed amount and the amount paid by the Plan. The contract says that you have a $550 annual dental benefit maximum. The record shows that you met the annual maximum benefit while processing this claim for the March 16, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the crown (D2790) provided on March 16, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for dermatology services provided by a participating provider on February 2, 2021.
You asked the Plan to waive the copayment for dermatology services. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied to the services that were provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for physician/practitioner services/specialist. You have been asked to pay a $25 copayment for dermatology services. Dermatology services fall within the physician/practitioner services/specialist 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 dermatology services provided by a participating provider on February 2, 2021.
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 you cannot walk and need in house care. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for pneumonia and are living at home with weakness and concern for falling. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a urine colony count (87086) provided on December 10, 2020.

You asked the Plan to pay for a urine colony count. You say that this is supported in the records. The Plan denied your request. The Plan says there are no results for this testing.

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 87086 is culture, bacterial; quantitative colony count, urine.

We find that CPT code 87086 is not supported in the medical record. Specifically, results for this testing were not included in the sibmitted documentation. Based on this information, we decided that Medicare rules for coverage of a urine colony count have not been met. Therefore, we decided that the Plan does not have to pay for a urine colony count (87086) provided on December 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 10, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 24, 2021 to March 24, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that you were told that this provider accepted this plan. You also say that you have been satisfied with the care you have received. 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 had network providers available who could have provided 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 provided on February 24, 2021 to March 24, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided on March 2, 2021, by an out of network (OON) provider.

You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that you would like this claim reprocessed for medical necessity The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered 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 had network providers available who could have provided 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 psychiatric diagnostic evaluation (90791) provided on March 2, 2021, by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room (ER) and inpatient hospital services rendered on February 1, 2021 to February 2, 2021.

You asked the Plan to waive the copayments for these services. You say that this was not an inpatient stay. 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 $90 copayment per visit for emergency care and a $250 copayment per day for days 1-7 per admission for inpatient hospital care.

Review of the file shows that you received ER services on February 1, 2021. You have been asked to pay a $90 copayment per visit for these services. These services fall within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

The file shows that you received inpatient hospital services from February 1, 2021 to February 2, 2021. You have been asked to pay a $250 copayment for these services. These services fall within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

The total amount you have been asked to pay for these services is $340. 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 emergency room (ER) and inpatient hospital services rendered on February 1, 2021 to February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on December 14, 2020.

You asked the Plan to pay for the bitewing x-rays. You say that you would like additional payment for this claim. The Plan denied your request. The Plan says the benefit maximum for this time period or occurrence had been reached.

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 $300 Annual Dental Reimbursement Allowance. The record shows that you met the annual maximum benefit while processing this claim for the December 14, 2020, date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and to pay more for the first intraoral periapical x-ray provided on March 23, 2021 by an OON provider.

You asked the Plan to pay for the problem focused limited oral evaluation or pay more for the first intraoral periapical x-ray. You say that you moved to a new area and were unable to find a participating provider who would be able to service your root canal. The Plan denied your request. The Plan says the problem focused limited oral evaluation is not a covered service. The Plan also says that you are responsible for 50% of the allowed amount as well as the excluded charges for the first intraoral periapical x-ray.

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 problem focused limited oral evaluation is not among those covered under this benefit. You are also responsible for a 50% coinsurance for intraoral periapical x-rays received OON, plus the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation and to pay more for the first intraoral periapical x-ray provided on March 23, 2021 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for outpatient surgical services provided on March 10, 2021.

You asked the Plan to waive the cost-sharing for outpatient surgical services. You say that you cannot afford these charges. The Plan denied your request. The Plan says these services processed correctly. The Plan has also indicated that the hospital has written off the $10.26 of non-covered charges.

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 $500 deductible and a 4% coinsurance for each outpatient hospital visit.

You have been asked to pay $497.40 towards your deductible and 4% ($219.55) of the remaining allowed amount for the outpatient surgery services at issue. 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-sharing for outpatient surgical services provided on March 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgery you had on December 1, 2020.

You asked the Plan to waive the coinsurance. You say that you should not have to pay this amount. The Plan denied your request. The Plan says you are responsible for the cost share.

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% coinsurance for out-of-network outpatient surgery. 

Review of the file shows that you had outpatient surgery services on December 1, 2020. You have been asked to pay a 50% coinsurance for the procedure, totaling $1,372.42. The procedure falls within the out-of-network outpatient surgery 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 outpatient surgery you had on December 1, 2020.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in another 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 in the Medicare rules section. 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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.