Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve the SNF services. You say that you cannot take care of yourself after right shoulder replacement surgery. The Plan denied your request. The Plan says a SNF admission is not medically necessary. The enrollee can be cared for at a lower level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, you received oral medications. You had stable vital signs. You were treated for pain with effect. Regarding rehabilitation services, you received physical therapy (PT) and occupational therapy (OT) in the acute hospital. You were at a contact guard assist level for functional mobility including gait to 75 feet with a cane. You required varying assist with activities of daily living. You were non-weight-bearing to your right upper extremity. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, you do not require skilled nursing or therapy services on a daily basis. As a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from October 3, 2020, to October 6, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford the charges. 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 $350 copayment for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from October 3, 2020, to October 6, 2020. Therefore, you are responsible to pay a $350 copayment for days 1-3 (October 3,2020, to October 5, 2020). $350 (copayment) x 3 (inpatient days) = $1,050. You have been asked to pay the total copayment amount of $1,050 for 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 provided from October 3, 2020, to October 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you do not require the daily skilled therapy or nursing services required to qualify for a skilled nursing facility admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from September 9, 2020, to September 14, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges. 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 $250 copayment for days 1-7 for inpatient hospital care. You had an inpatient hospital stay from September 9, 2020, to September 14, 2020. Therefore, you are responsible to pay a $250 copayment for days 1-5 (September 9, 2020, to September 13, 2020). $250 (copayment) x 5 (inpatient days) = $1,250. You have been asked to pay the total copayment amount of $1,250 for 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 provided from September 9, 2020, to September 14, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on December 21, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that you received a bill for the colonoscopy, and it is a lot of extra money. 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 $100 per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. You have been asked to pay a $100 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show biopsies were performed during the colonoscopy which is considered 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 for the colonoscopy provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on December 11, 2020.
You asked the Plan to waive the copayment for specialist services. You say that you thought due to Covid-19 these services would be covered and waived. 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 $45 copayment for physician/practitioner services/in-network/specialist. You have been asked to pay $26.65 which is less than your copayment amount of $45 for specialist services. Specialist services fall within the physician/practitioner services/in-network/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 specialist services provided by a participating provider on December 11, 2020.
We note your complaint about reading that copayments would be waived due to Covid-19. 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for skin substitute graft application services (CPT 15275) provided to the enrollee on September 16, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was not billed correctly.
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 15275 is "Application of skin substitute graft to face, scalp, feet, etc., total wound surface area up to 100 sq cm; first 25 sq cm or less." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the provider reported application of a skin substitute for date of service September 16, 2020, however the product used was not reported with procedure. Therefore, the denied code cannot be reimbursed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for skin substitute graft application services (CPT 15275) provided to the enrollee on September 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you need rehabilitation services in order to go home without extreme pain. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you have a medical history including hypertension and osteoarthritis and that you had a mechanical fall at home and were admitted to an acute hospital under an observational level of care. You have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter the intermittent skilled services can be provided at a lower level of care than a SNF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of a Dorsal Root Ganglion neurostimulator for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records show that this request would exceed the allowed limit of two spinal cord stimulator trials or one permanent spinal cord stimulator.
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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this type of stimulation is considered experimental and investigational at this time. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of a Dorsal Root Ganglion neurostimulator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for the intraoral periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335) provided December 4, 2020 from an out-of-network provider.
You asked the Plan to provide additional reimbursement for the intraoral x-rays and resin-based composites. You say that the services were medically necessary and you would like to be reimbursed for the full amount paid. The Plan denied your request. The Plan says that when you get services from an out-of-network provider you are responsible for the difference between the Plan's allowed amount and the total cost charged by the provider.
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 intraoral x-rays and resin-based composites up to the Plan's allowed amount when the services are medically necessary and reasonable. We looked at the file and Medicare rules. You received services from an out-of-network provider. The Plan has provided reimbursement for the full Maximum Allowable Charge for the services. Based on this information, we decided that the Plan does not have to provide additional reimbursement for the intraoral periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335) provided December 4, 2020 from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an automatic blood pressure monitor (A4670) with sales tax purchased on October 31, 2020, from an online retailer.
You asked the Plan to pay for an automatic blood pressure monitor with sales tax. You say that the requested item is a necessity because it is your health tracking machine. The Plan denied your request. The Plan says rules for payment have not been met because the requested item was purchased from a non-contracted provider.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of durable medical equipment have not been met. Specifically, the services at issue were provided by a provider that appears to not be certified for Medicare. The provider at issue did not come up on the Medicare.gov search for durable medical equipment suppliers serving your area. There was no documentation supplied by the provider to verify that they are certified by Medicare. Furthermore, Medicare does not reimburse separately for sales tax. Therefore, we decided that the Plan does not have to pay for an automatic blood pressure monitor (A4670) with sales tax purchased on October 31, 2020, from an online retailer.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the eyeglasses (frames and lenses) purchased from an out-of-network provider on September 4, 2020.
You asked the Plan to pay for the eyeglasses. You say that you used a provider other than the one recommended because the overall cost for the eyewear was lower. You cannot see who benefits from the Plan's recommendation, as the Plan would only pay up to $250 regardless and the rest of the cost would come out of your pockets. The Plan denied your request. The Plan says that you were referred to a specific provider in order to use your benefits, but you chose to use a different, out-of-network provider. The Plan does not cover out-of-network items or services, except in limited circumstances, such as an emergency.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan will pay up to $250 for one pair of eyeglasses (frames and lenses) or contact lenses every benefit period. We looked at the file and the Plan's rules. The Plan made their denial based on the rules for out-of-network coverage outlined in chapter 3 of your contract. These rules state that the Plan does not cover out-of-network medical services except in limited circumstances. The Plan requires you to use a Plan-directed primary care physician to coordinate your medical care.
However, these rules only apply to Medicare-covered medical services. Medicare does not cover routine eyewear or services, but the Plan offers a supplemental benefit that exceeds Medicare coverage. Services provided under supplemental benefits are not subject to Medicare rules, as they are not Medicare-covered.
If we look at the routine dental coverage, which is another supplemental benefit, we can see that it is clearly specified that the listed dental services will only be covered when they are provided in-network. There is no such statement regarding supplemental vision care benefits, which means there is nothing that states that supplemental routine vision care must be provided in-network.
The Plan's contract only states that you are permitted an allowance of $250 for one pair of eyewear every benefit period. The contract does not specify that these services must be received in-network or from a Plan-directed provider. Because this information is not clearly specified and the coverage only extends to a $250 allowance with no listed requirements or exclusions, it is reasonable to assume that any eyewear can be purchased from any provider and will be reimbursed up to the allowed amount of $250.
Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have been met. Therefore, we decided that the Plan has to pay up to the $250 allowed maximum for the eyeglasses (frames and lenses) purchased from an out-of-network provider on September 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic footwear (L3002, L3216).

You asked the Plan to pre-approve orthopedic footwear. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says orthopedic footwear is not a covered benefit under your contractual policy or by Medicare for your condition.

Medicare rules state that supportive devices for the feet (such as orthopedic footwear) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthopedic footwear may be appropriate for you, neither Medicare nor the Plan provides coverage of orthopedic footwear for your condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic footwear (L3002, L3216).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 8, 2020, by an OON provider.
You asked the Plan to pay for lab work. You say that your lab performed all the tests that were ordered by the
referring physician. You say that you would like this claim reprocessed and paid. The Plan denied your request.
The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that
the referring provider is out-of-network.
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 lab work provided on January 8, 2020, by an OON
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist visit and an ultrasound provided on November 5, 2020.
You asked the Plan to waive the copayments for a specialist visit and an ultrasound. You say that the doctor did little to treat your condition and you are still suffering from it. 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 $45 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay a $110 copayment for ultrasounds. You had a specialist visit on November 5, 2020. Therefore, you are responsible to pay the $45 copayment. You received an ultrasound on November 5, 2020. Therefore, you are responsible to pay the $110 copayment. The total amount you owe is: $155. You have been asked to pay the total copayment amount of $155 for a specialist visit and an ultrasound. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for a specialist visit and an ultrasound provided on November 5, 2020.