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

We decided that the Plan does not have to waive the copayment forthe office visits provided on August 23, 2019 and September 20, 2019.You asked the Plan to waive the copayment forthe office visits. You say that you were informed there would be no copayment. You say that you saw a nurse but the visits were billed for a specialist. 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 $45 for each covered visit or consultation in an outpatient location with a specialist. Covered services medically-necessary medical care or surgery services furnished in a physician's office.You have been asked to pay a $45 copayment for each office visit. The total amount you owe is $90 ($45/visit x 2 visits = $90). The office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were treated at a specialist's office. 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 forthe office visits provided on August 23, 2019 and September 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on September 5, 2019.You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to reimburse you 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 eyeglasses. We found no exception that would require the Plan to reimburse you for this items. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on September 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy and pulp vitality tests provided on October 16, 2019.You asked the Plan to pay for the endodontic therapy and pulp vitality tests. You say that you had an infected tooth and were referred to this provider for a root canal to save3 teeth. You also say that a root canal was recommended because if you had the infected tooth pulled, you would have lost 3 teeth.The Plan denied your request. The Plan says these procedures are not covered by your contract.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 itemsor services are not among those covered under this benefit. The contract also clearly states that endodontic services are not covered.Therefore, we decided that the Plan does not have to pay forthe endodontic therapy and pulp vitality tests providedon October 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that the enrollee's medical condition is fragile and she needs frequent physician oversight of her rehab program and would benefit from intensive services.The Plandenied your request. The Plansaysshe does not require acute medical care nor intensive therapy.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 enrollee had a prolonged hospital stay due to critical limb ischemia. The enrollee required amputation, after failing IV antimicrobials and conservative care. Now, she is wearing an off-loading shoe and is hemodynamically stable, without fever, and is non-toxic. The enrollee is able to make needs known and there are no surgical site or wound care complications noted. Records do not indicate that there are significant, or complex medical/nursing issues that require frequent physician oversightin an acute hospital setting. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lower level of care.  In this case, the enrollee is mostly requiring minimal assist for functional transfers and ADLsand a less intensive, longer duration of therapy can allow for measurable gains to be attained within a predicted period.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 Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe paramedic intercept services provided by "the provider" on July 11, 2019.You asked the Plan to pay forthe paramedic intercept services. You say that the paramedic intercept service was medically necessary and cannot be provided by the Town of Webster ambulance service.The Plan denied your request. The Plan says this item is not a covered benefit.The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area.Therefore, we decided that the Plan does not have to pay forthe paramedic intercept services provided by "the provider" on July 11, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveProlia.You asked the Plan to pre-approveProlia. You say that the Prolia medically necessary.The Plan denied your request. The Plan says that the enrollee does not have osteoporosis so the Prolia is 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 pre-approve Prolia. Our reviewer says that the Prolia is medically necessary. Our physician reviewer found the risk of fracture is high enough to warrant therapy to increase bone density. Since the enrollee's renal function is low and the enrollee has already been on alendronate for more than 5 year, Prolia is a reasonable choice.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 been met.Therefore, we decided that the Plan has to pre-approveProlia.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. Ifwe decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary or rest home visit provided on May 23, 2019.You asked the Plan to pay fora domiciliary or rest home visit. You say that the provider rendered medically necessary services in good faith.The Plan denied your request. The Plan says these services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve theitem/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 fora domiciliary or rest home visit provided on May 23, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 2 custom fabricated abutments, 2 abutment supported porcelain/ceramic crowns, and the porcelain or ceramic pontic provided on July 24, 2019.You asked the Plan to pay forthe custom fabricated abutments, abutment supported porcelain/ceramic crowns, and pontic. You say that you did not have an option to getting implants. You also say that this was not a cosmetic decision you made, but it was a medical decision made by the provider.The Plan denied your request. The Plan says these services are not covered benefits under your plan.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 forthe 2 custom fabricated abutments, 2 abutment supported porcelain/ceramic crowns, and the porcelain or ceramic pontic provided on July 24, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foranesthesia provided on July 25, 2019.You asked the Plan to waive the coinsurance foranesthesia. You say that you were told that you would not owe anything.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 20% coinsurance for outpatient hospital services.You received anesthesia on July 25, 2019. The total allowed amount is $133.46 and 20% of that is $26.70.  You have been asked to pay the total coinsurance amount of $26.70 for anesthesia. Anesthesia 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 youenrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance foranesthesia provided  on July 25, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe corneal transplant provided on August 19, 2019.You asked the Plan to waive the coinsurance forthe corneal transplant. You say that you were informed prior to surgery that the provider was in-network. 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 termsall cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for out-of-network surgery services.You have been asked to pay $3,104.01, which is 50% of the allowed amountfor the corneal transplant. The allowed amount is $6,208.02 (50% x $6,208.02 = $3,104.01). The corneal transplant falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the provider is out-of-network. 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 forthe corneal transplant provided on August 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient stay for surgery provided from May 16, 2019 to May 17, 2019.You asked the Plan to pay for the inpatient stay. You say that you thought the Plan was a secondary payer to Medicare. 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an inpatient stay for surgery provided from May 16, 2019 to May 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora colonoscopy with a biopsy (45380) provided on September 10, 2019. You asked the Plan to waive the copayment fora colonoscopy with a biopsy. You say that your doctor ordered this as a preventative service,but the provider billed it as diagnostic. You say prior to the procedure you were informed by a representative that the screening would be paid in full.The Plan denied your request. The Plan says outpatient surgery services have a $350 copayment. They further say that the screening colonoscopy resulted in a diagnostic procedure which resulted in a biopsy.The rules say a plan must disclose to its enrollees inclear, 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 surgery services. You have been asked to pay a $350 copayment for a colonoscopy with biopsy. This service falls within the outpatient surgery services benefit category. The record shows that your screening colonoscopy resulted in the removal of a biopsy and therefore became a diagnostic 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 fora colonoscopy with a biopsy (45380) provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services provided on September 4, 2019.You asked the Plan to waive the copayment for the outpatient hospital services. You say that you feel you should not be responsible for this cost share amount and you would like the plan to reconsider your request.The Plan denied your request. The Plan says you received outpatient hospital services on the date of service at issue in this appeal. The plan states the correct copayment has applied per your contract with the plan. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for each outpatient hospital and observation service. We looked at the file, the plan's contract and Medicare rules. The file shows you received outpatient hospital services on September 4, 2019. You have been asked to pay a $350 copayment for the outpatient hospital services. The outpatient hospital services fall within the Outpatient hospital 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 the outpatient hospital services provided on September 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe rituximab, diphenhydramine HCL and methylprednisolone sodium succinate injections provided from September 10, 2019 to September 25, 2019.You asked the Plan to waive the coinsurance forthe injections. You say that you cannot afford to pay the cost-sharing.The Plan denied your request. The Plan says that claims 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay 20% coinsurance for the injections. The injections fall within the Medicare Part B prescription drugs benefit category. This means that you have been askedto 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 forthe rituximab, diphenhydramine HCL and methylprednisolone sodium succinate injections provided from September 10, 2019 to September 25, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on August 29, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you will not pay the emergency room copayment because you do not feel you are responsible. 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 $90 copayment for emergency services at an in-network emergency room. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you received services during your emergency room 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 emergency room visit provided on August 29, 2019.
Your complaint about misreading or mixing up your blood work is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral wrist hand orthoses (CPT Code L3916) provided to the enrollee on January 11, 2019.
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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 orthoses. Our reviewer says that the enrollee does not meet criteria for the orthoses ordered. Our physician reviewer found the documentation in the case file does not support that the requested wrist/hand orthoses were medically reasonable and necessary for the enrollee in this case. An appropriate history and a physical examination of the wrists would reasonably be required to adequately assess whether the wrist/hand orthoses were medically reasonable and necessary. The documentation does not support that the wrist/hand orthoses were medically reasonable and necessary in this case, as there is no documentation of a credible physical examination of the wrists. 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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for bilateral wrist hand orthoses (CPT Code L3916) provided to the enrollee on January 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on August
21, 2019.
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that at your last dentist
appointment, no x-rays were taken. You also say that you had a difficult time finding an in-network dentist, and
your previous dentist was out-of-network. The Plan denied your request. The Plan says the benefits for this
service have been satisfied and the frequency limitation has been exceeded. The Plan also says that the claim
submission indicates that 2 periapical x-rays were performed, one of which was paid at 100% and
the other denied due to frequency limitations.
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, intraoral x-rays are limited to one set
per calendar year. The record shows that you received 2 intraoral periapical x-rays on August 21, 2019, one of
which was covered at 100% by the Plan, and your intraoral x-rays benefit was then exhausted. Therefore, we
decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on August 21,
2019.