Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis - adult (D1110) provided September 22, 2020.

You asked the Plan to pay for the oral exam and dental cleaning. You say that the services should be covered. The Plan denied your request. The Plan says the services were not provided by a network provider and therefore are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the oral exam and dental cleaning when they are provided by a network provider. 

We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan at the time of the service. We found no exception that would require the Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of the oral exam and dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis - adult (D1110) provided September 22, 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 the enrollee needs IRF services. The Plan denied your request. The Plan says the services are not medically necessary.

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. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy provided by a participating provider on October 15, 2020.

You asked the Plan to waive the coinsurance for chemotherapy. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Medicare Part B prescription drugs/in-network/chemotherapy drugs. 

You have been asked to pay a 20% coinsurance of the allowed amount for chemotherapy. The total allowed amount is $77.01. The total amount you are being asked to pay is $15.40 ($77.01 x 20% = $15.40). The correct coinsurance has been applied to the injection that was provided. Chemotherapy falls within the Medicare Part B prescription drugs/in-network/chemotherapy drugs 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 chemotherapy provided by a participating provider on October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you in full for eyeglasses provided on September 25, 2020.

You asked the Plan to reimburse you in full for the eyeglasses. You say that the Plan promised to pay in full for the eyeglasses. The Plan denied your request. The Plan says the claim will be processed to reimburse you $200, which is the maximum allowance for the Plan's supplemental eyewear benefit.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services with a $200 allowance for supplemental eyewear, every year. 

We looked at the file and the Plan's rules. The file shows that the Plan has processed a reimbursement to you for $200, which is the maximum supplemental eyewear benefit. The file also shows that the Plan received a call from you after the eyewear had been purchased. There is no record of a call to the Plan prior to the eyewear purchase. Therefore, we decided that the Plan does not have to reimburse you in full for eyeglasses provided on September 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kerecis Omega3, per square centimeter (Q4158).

You asked the Plan to pre-approve Kerecis Omega3, per square centimeter (Q4158). You say that the enrollee has multiple non-healing wounds that have failed conventional treatment. The Plan denied your request. The Plan says the enrollee does not have serial wound measurements spanning thirty consecutive days.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Kerecis omega3, per square centimeter (Q4158). Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested Kerecis Omega 3 is not a considered standard of care application for ulcerations. There is no documentation that this injured enrollee has undergone continual extensive wound dressing changes with wound debridement and wound VAC. It is also unclear as to whether these ulcerations have a chance of healing regardless of skin substitute dressings because of the underlying osteomyelitis. Therefore, the Kerecis Omega 3 is not considered medically reasonable and necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Kerecis Omega3, per square centimeter (Q4158) have not been met. Therefore, we decided that the Plan does not have to pre-approve Kerecis Omega3, per square centimeter (Q4158).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 31, 2020 provided on December 31, 2020 by a non-participating provider.

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 the services were rendered by a non-participating provider without 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 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 laboratory services rendered on December 31, 2020 provided on December 31, 2020 by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental case management (D9992) provided on January 26, 2021.

You asked the Plan to pay for the dental case management. You say that you were sent a bill for only calling the provider. The Plan denied your request. The Plan says this service is not covered 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 for the dental case management (D9992) provided on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on December 30, 2020.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you would like these services to be covered. The Plan denied your request. The Plan says your $500 benefit max was met before the processing of this claim.

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 $500 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on July 16, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0481) provided on July 29, 2020.
You asked the Plan to pay for drug testing. You say that these tests were medically necessary. The Plan denied your request. The Plan says these tests were not billed with the correct POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (80307, G0481) provided on July 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay on August 27 to September 4, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the Plan's cost-sharing is unfair. The Plan denied your request. The Plan says the correct copayment was 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 $250 copayment per day for the first 5 days for each Medicare-covered hospital stay. You have been asked to pay $1,250, or a $250 copayment per day for the first 5 days of an inpatient hospital stay. An inpatient hospital stay falls 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. 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 inpatient hospital stay on August 27 to September 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant, bone graft at time of implant placement, surgical extraction, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia provided on January 5, 2021.

You asked the Plan to pay for the endosteal implant, bone graft, surgical extraction, and intravenous moderate (conscious) sedation/analgesia. You say that you believe you should receive $1,500 in coverage for these services. The Plan denied your request. The Plan says this dentist is excluded from rendering services under this program.

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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant, bone graft at time of implant placement, surgical extraction, first 15 minutes of intravenous moderate (conscious)
sedation/analgesia, and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia provided on January 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided December 4, 2020 to December 29, 2020.
You asked the Plan to waive the copayment for the SNF services. You say that you received a bill for a copay amount of $625. You were told it was for additional days spent after the 20 days of rehabilitation were completed. These additional charges were never communicated to you by the provider. The Plan denied your request. The Plan says the enrollee was in SNF care for a total of 26 days. The claim was processed and the correct copayment was applied per the Evidence of Coverage.
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 $0 copayment each day for days 1-20 and $125 copayment for days 21-28 $0 copayment for additional days up to 100 days. You have been asked to pay $625 ($125 x 5 days) for the SNF services. The SNF services falls within the Skilled nursing facility (SNF) care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided December 4, 2020 to December 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram provided on November 4, 2020.
You asked the Plan to waive the copayment for the electrocardiogram. You say that you never had to pay a copayment before for this test. The Plan denied your request. The Plan says you were charged this copayment 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 $10 copayment for Outpatient Diagnostic Tests. You have been asked to pay a $10 copayment for the electrocardiogram. The electrocardiogram falls within the Outpatient Diagnostic Tests 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 electrocardiogram provided on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 6, 2020 by an out of network provider.
You asked the Plan to pay for the office visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 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 services at issue in this appeal. The Plan did not pre-approve the service 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 the office visit provided on November 6, 2020 by an out of network provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital service provided on October 26, 2020.
You asked the Plan to waive the copayment for the fine needle aspiration biopsy, including ultrasound guidance (10005). You say that you cannot afford the copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $250 copayment for Outpatient Hospital Services. You have been asked to pay a $250 copayment for the fine needle aspiration biopsy, including ultrasound guidance (10005). the fine needle aspiration biopsy, including ultrasound guidance (10005) falls 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 service provided on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) wound debridement services (97597, 97598) provided on January 5, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that please review the attached documentation which supports payment of CPT 97597 and 97598. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 outpatient office visit (99203) wound debridement services (97597, 97598) provided on January 5, 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 chiropractic services provided on December 2, 2020.
You asked the Plan to pay for the services provided. You say that you were informed that there is no visit maximum for chiropractic services. The Plan denied your request. The Plan says the enrollee already received the maximum about of coverage allowed for this service.
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 Plan offers a chiropractic benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the rules. The file shows that the enrollee received extraspinal manipulative treatment, electrical stimulation, and mechanical traction therapy. Although these services are not covered by Medicare when provided by a chiropractor, the Plan offers a benefit that exceeds Medicare coverage. The Plan allows 30 visits for routine services. However, the records show that the enrollee received 30 visits prior to the date of service at issue. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on December 2, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 24, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 24, 2020.