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

We decided that the Plan does not have to waive the copayment for ambulance services provided on July 18, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you already paid the $250. The Plan denied your request. The Plan says you had two (2) ambulance transportations on July 18, 2020.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you transported by ambulance two different times, by two different ambulance companies. You already paid $250 for one (1) transport. Therefore, you are asked to pay a $250 copayment for this ambulance transport. The health plan contract says that enrollees must pay a $250 copayment for each one-way Medicare-covered ground trip. 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 ambulance services provided on July 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 12, 2020.

You asked the Plan to waive the copayment for an ultrasound. You say that you feel that you should only owe a $20 copayment because an ultrasound should not be considered a diagnostic radiology test. 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 $125 copayment for radiological diagnostic services, including ultrasounds.

You have been asked to pay the allowed amount of $112.38, which is less than the $125 copayment for an ultrasound. 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 copayment for an ultrasound provided on February 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on November 6, 2020.
You asked the Plan to waive the copayment for the ambulance ride. You say that you did not have time to decline the ambulance ride. You say you have limited income. The Plan denied your request. The Plan says you have been asked to pay 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 $200 copayment per one-way trip (includes ground and air transport) for each Medicare-covered ambulance service. You have been asked to pay a $200 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 ambulance ride provided on November 6, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the member has a life-threatening condition that
requires physician oversight in an inpatient setting. The Plan denied your request. The Plan says that the
enrollee can safely receive the services needed, 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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for coronary artery
bypass grafting. The enrollee's medical problems are stable. 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. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, problem focused limited oral evaluation, and preventive procedure provided on July 7, 2020.
You asked the Plan to pay for the first intraoral periapical x-ray, problem focused limited oral evaluation, and preventive procedure. You say that you were not advised that this treating provider had opted out of Medicare. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective December 21, 2015, to December 21, 2021. The Plan also says that services performed by a privately contracted provider are not covered by the 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. The record shows that you did not contact the Health Plan in regard to your cost share or coverage for the above referenced services prior to the date of service. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, problem focused limited oral evaluation, and preventive procedure provided on July 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation service (A0429) and the emergency room visit (99284) provided on November 4, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services 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 $350 for Medicare-covered ambulance services per trip and $90 for each covered emergency visit.

You have been asked to pay a $440 copayment ($350 + $90) for the ambulance service and the emergency room visit provided. 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 ambulance transportation service (A0429) and the emergency room visit (99284) provided on November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing X-rays (D0274) received December 2, 2020.

You asked the Plan to pay for the bitewing X-rays. You say that the X-rays you received in March were outdated and you needed new X-rays taken. The Plan denied your request. The Plan says coverage of bitewing X-rays is limited to once per year.

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 service exceeds that covered under this benefit. The Plan has submitted evidence that you received bitewing X-rays on March 5, 2020. The Plan's benefit was exhausted on December 2, 2020. Therefore, we decided that the Plan does not have to pay for the bitewing X-rays (D0274) received December 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that 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 this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a skilled nursing facility setting. The enrollee can continue to effectively receive services at the current facility with a transition to a home or community setting upon discharge. There are no extenuating factors that would require a SNF admission.

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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body, endosteal implant tooth #22, #27 (D6010) removal of impacted tooth, partially bony, tooth #32 (D7230).
You asked the Plan to pre-approve the dental services. You say that this should be covered because the procedure is necessary to allow you to eat properly and it is not for cosmetic purposes. The Plan denied your request. The Plan says these services are not covered under the plan benefits.
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 health plan contract specifically says that any services not listed is not covered by the plan. 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 pre-approve surgical placement of implant body, endosteal implant tooth #22, #27 (D6010) removal of impacted tooth, partially bony, tooth #32 (D7230).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 2, 2020, October 28, 2020, and November 25, 2020.
You asked the Plan to waive the copayment for the ambulance transports. You say that a medical transport is the only way you could be discharged to home. You say that the charges are a financial hardship. 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 a $240 copayment for each one-way Medicare-covered ground ambulance trip. You have been asked to pay a $240 copayment for each ambulance transport. The total amount you owe is $720 ($240/transport x 3 transports = $720). The ambulance transports fall within the "Ambulance 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 ambulance transport provided on September 2, 2020, October 28, 2020, and November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, endosteal implant, and removable appliance therapy provided on November 3, 2020 by an OON provider.

You asked the Plan to pay for the extraction, endosteal implant, and removable appliance therapy. You say that this provider was recommended to you by your general dentist. You also say that you believe these services should be covered. The Plan denied your request. The Plan says no coverage or benefits are available when services are provided by a dentist who does not participate in the Plan's network.

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 OON. Therefore, we decided that the Plan does not have to pay for the extraction, endosteal implant, and removable appliance therapy provided on November 3, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November 10, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you were told that you would not owe a copayment for the ambulance services. 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 $225 copayment for ambulance services. You have been asked to pay a $225 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on November 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0651) and segmental pneumatic appliance (E0667).

You asked the Plan to pay for a pneumatic compression device and appliance. You say that you have attached all the supporting documentation needed to finish processing the claim. The Plan denied your request. The Plan says the records do not support that the enrollee does not meet the Medicare criteria.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 

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 a pneumatic compression device and appliance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has secondary lymphedema. The provided documentation does not indicate that a four-week trial of compliance with conservative measures has been attempted. The elements of the local coverage determination are not satisfied. The requested service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a pneumatic compression device and appliance have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0651) and segmental pneumatic appliance (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion services (Q0138, 96365, J7050) provided on August 12, 2020 to August 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON infusion services. You say that this was medically necessary. The Plan denied your request. The Plan says this was 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 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 infusion services (Q0138, 96365, J7050) provided on August 12, 2020 to August 24, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical supplies (S1015, S8301) used September 23, 2020.
You asked the Plan to pay for the medical supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says the CPT codes billed are not eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes S1015 and S8301 are not supported in the medical record. Specifically, per the 2020 National Physician Fee Schedule, these codes are marked with a status of "I" which means they are not valid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the medical supplies have not been met. Therefore, we decided that the Plan does not have to pay for medical supplies (S1015, S8301) used September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 1, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the laboratory services are not supported in the medical record. Specifically, these services should be reported with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 1, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ultrasound provided on April 30, 2020.

You asked the Plan to reduce the copayment for the ultrasound. You say that you were originally billed $75.55 and then received another bill for $17.99. You would like the $17.99 waived. The Plan denied your request. The Plan says you have been asked to pay 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 325 copayment per day for Medicare-covered diagnostic radiology services ($100 ultrasound). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $100 copayment for the ultrasound.

You have been asked to pay a $93.54 copayment for the ultrasound. The 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 reduce the copayment for the ultrasound provided on April 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered from December 17, 2020 to December 21, 2020.

You asked the Plan to waive the copayment for these services. You say that the duration of the stay was out of your control. 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 $372 copayment per day for days 1-5 for in-network inpatient hospital care.

Review of the file shows that you received three days of inpatient hospital care from December 17, 2020 to December 21, 2020. You were not assessed a copayment for the date of discharge on December 21, 2020. You have been asked to pay a $372 copayment per day for these services, for a total of $1,116. These services fall within the in-network 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 the inpatient hospital services rendered from December 17, 2020 to December 21, 2020.