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

We decided that the Plan does not have to waive the coinsurance for a sleep study provided by a participating provider on December 30, 2020.
You asked the Plan to waive the coinsurance for a sleep study. You say that you do not agree with this coinsurance. 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 outpatient diagnostic tests/sleep study. You have been asked to pay a 20% coinsurance of the allowed amount for a sleep study. The total allowed amount is $325. The total amount you are being asked to pay is $65 ($325 x 20% = $65). A sleep study falls within the outpatient diagnostic tests/sleep study 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 a sleep study provided by a participating provider on December 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for screening mammography, bilateral, including CAD when performed (77067) screening digital breast tomosynthesis, bilateral (77063) provided January 5, 2021.
You asked the Plan to waive the copayment for the mammogram. You say that you went to the hospital to have mammogram done like always. The hospital is in network and does accept insurance. You feel you should not be responsible for this bill. The Plan denied your request. The Plan says the claim was processed and the correct cost share was applied for out of network provider 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 20% coinsurance for out of network providers.
You have been asked to pay $14.67 for the mammogram. The mammogram 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 screening mammography, bilateral, including CAD when performed (77067) screening digital breast tomosynthesis, bilateral (77063) provided January 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walk-in tub provided on June 19, 2020.
You asked the Plan to pay for a walk-in tub. You say that the requested item is necessary to care for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a walk-in tub provided on June 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the transport chair provided on January 27, 2021.
You asked the Plan to waive the coinsurance for the transport chair. You say that you never rented a wheelchair and have paid for all your equipment with a credit card. 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 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-covered durable medical equipment.
You have been asked to pay $4.80, which is 20% of the allowed amount for the transport chair. The allowed amount is $24 (20% x $24 = $4.80). The transport chair falls within the "Durable medical equipment (DME) and related 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 coinsurance for the transport chair provided on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for immunization services provided to the enrollee on September 2, 2020.

You asked the Plan to pay for the services. You say that you are seeking reimbursement. The Plan denied your request. The Plan says this should have been submitted to the pharmacy vendor.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on September 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 13, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 13, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bendeka (Bendamustine) for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is not recommended to be used again if previously used.

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found as the enrollee has not responded to Bendamustine, it cannot be approved.

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Bendeka (Bendamustine) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for gene analysis of prostate tumor tissue, profiling by real-time PCR of 3 genes (CPT code 81551) provided to the enrollee on December 21, 2020.
You asked the Plan to pay for the laboratory services. You say that this service should be covered based on Medicare guidelines. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for gene analysis of prostate tumor tissue, profiling by real-time PCR of 3 genes (CPT code 81551) provided to the enrollee on December 21, 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 you cannot care for yourself and these services are medically necessary. The Plan denied your request. The Plan says that the services you need are not inherently complex or require a registered nurse to safely perform.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the prophylaxis (D1110) received January 15, 2021 from an out-of-network provider.

You asked the Plan to pay an additional amount for the prophylaxis. You say that the plan contract shows a $0 copayment for cleanings. The Plan denied your request. The Plan says for services obtained Out-of-network the Plan only pays up to a certain amount. If you choose to see an out-of-network dentist, you might be billed for any amount greater than what the Plan pays.

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 payment is in excess of that which is covered under this benefit. You received the requested service out-of-network. The Plan paid 100% of the cost, up to the allowable amount for this service. You are responsible for paying any amount in excess of the Plan's allowed amount. Therefore, we decided that the Plan does not have to pay an additional amount for the prophylaxis (D1110) received January 15, 2021 from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on December 23, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you feel this service should be covered by your dental insurance. The Plan denied your request. The Plan says this procedure is limited to twice per calendar year. The Plan also says that this service exceeded your contractual insurance 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, oral exams are limited to two per calendar year. The record shows that you received a periodic oral exam on February 5, 2020, and a problem focused limited oral evaluation on May 11, 2020, and your oral exams benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on December 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the foot x-ray (CPT code 73620-left), the hand x-ray (CPT Code 73120-right), the hand x-ray (CPT Code 73120-left), the hip x-ray (CPT Code 73502-left) provided on July 30, 2020.
You asked the Plan to waive the copayment for the x-rays. You say that you should not pay due to providers billing practices. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
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 show that you received four (4) x-rays provided on July 30, 2020. You were asked to pay a $10 copayment per x-ray. Your 2020 EOC states that enrollees must pay a $10 copayment for most X-rays and
ultrasounds. 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 foot x-ray (CPT code 73620-left), the hand x-ray (CPT Code 73120-right), the hand x-ray (CPT Code 73120-left), the hip x-ray (CPT Code 73502-left) provided on July 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 3, 2020.
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, the services provided were part of an expanded pharmacogenomic panel. This means that these services should be reported with code 81479. 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 April 3, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on October 13, 2020, by an out of network (OON) provider.

You asked the Plan to pay for psychotherapy services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on October 13, 2020, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Radicava (J1301).
You asked the Plan to pre-approve Radicava. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested injection 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 Radicava. Our reviewer says that the requested drug, Radicava, is not medically necessary. Our physician reviewer found the records provided for review indicated that the enrollee's FVC value was 76% (slightly below 80%). The reviewer found that the enrollee scored below 2 on at least 1 subsection of the ALSFRS-R. Therefore, the reviewer found that, in this setting, it cannot be concluded based on the information provided that the drug would be expected to afford any meaningful benefit 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 Radicava have not been met. Therefore, we decided that the Plan does not have to pre-approve Radicava (J1301).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on January 6, 2021.
You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.
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 vision services provided on January 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on November 19,
2020.
You asked the Plan to pay for the periodontal maintenance. You say that you feel you should not have to pay
the deductible because you only went to the dentist once. The Plan denied your request. The Plan says your $75
deductible was not reached prior to this appointment. The Plan also says that the $75 deductible applies to the
periodontal maintenance cleaning.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, you must pay the $75 annual
deductible on covered dental services before coverage begins. Therefore, we decided that the Plan does not
have to pay for the periodontal maintenance provided on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation and additional intraoral x-ray, and to pay more for the first intraoral periapical x-ray provided on January 27, 2021 by an OON provider.
You asked the Plan to pay for the comprehensive periodontal evaluation and additional intraoral x-ray, or pay more for the first intraoral periapical x-ray. You say that you believe these services should be covered. The Plan denied your request. The Plan says your benefits for the comprehensive periodontal evaluation and additional intraoral x-ray have been satisfied and the frequency limitations have been exceeded. The Plan also says these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.
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, periodontal exam and comprehensive oral evaluation are limited to one procedure code every three years. The record shows that you received a comprehensive oral evaluation on September 14, 2020 and your periodontal exam and comprehensive oral evaluation benefit has been exhausted. The contract includes intraoral x-rays and are limited to one procedure per calendar year. The record shows that you received a first intraoral x-ray on January 27, 2021 which was covered by the Plan and your intraoral x-rays benefit has been exhausted. You are also responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation and additional intraoral x-ray, and to pay more for the first intraoral periapical x-ray provided on January 27, 2021 by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services from September 19, 2020, through October 18, 2020.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says SNF services provided after the last covered day are not medically necessary.
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 pay for continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She had uncomplicated wound care to a skin tear on her left elbow and right knee and her right lower extremity. Regarding rehabilitation services, the enrollee did not receive nor require any skilled services for the dates in question. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does 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 continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation SNF services from September 19, 2020, through October 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites provided on January 15, 2021.
You asked the Plan to pay for the resin-based composites. You say that you thought these services would be covered. The Plan denied your request. The Plan says these procedures are not a benefit under your dental 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 two resin-based composites provided on January 15, 2021.