Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from October 4, 2019.You asked the Plan to pay forhome health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this claim was submitted with an inappropriate type of bill.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was submitted on type on bill 0323. This is not a valid type of bill for the services billed..Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from October 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH level care is medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found ongoing LTACH coverage as of 3/2/2020 is not medically necessary. The enrollee has been weaned from the ventilator. The enrollee's long-term prognosis is noted to be poor. There is no evidence that the enrollee requires ongoing LTACH services. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on November 20, 2019.
You asked the Plan to reimburse you for the hearing aids. You say that you were told by the provider that they accepted your insurance plan and that the Plan would cover $1500 toward the cost of the hearing aids. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. 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.
We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the hearing aids. We found no exception that would require the Plan to pay for the hearing aids. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99212) provided
December 6, 2019.
You asked the Plan to waive the copayment for the outpatient office visit. You say that you have now
established a relationship with this provider and you cannot continuously afford to pay 50% of these charges so
you are requesting reconsideration for additional coverage. The Plan denied your request. The Plan says this
claim was processed correctly. Previous one time exception payments were already allowed for this provider.
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 50% coinsurance
for out-of-network provider and professional services for Physician/Practitioner services, including
doctor's office visits.
You have been asked to pay 50% co-insurance for out-of-network provider and professional services for the
outpatient office visit. the outpatient office visit falls within the Physician/Practitioner services, including
doctor's office visits 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 office
visit (99212) provided December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Puraply Skins substitute.
You asked the Plan to pre-approve Puraply Skins substitute. 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. 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 Puraply Skins substitute. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have bilateral foot wounds, following bilateral transmetatarsal amputations, in the setting of diabetes, neuropathy and peripheral vascular disease. The enrollee's wounds appear to be continually evolving, with old wounds healing and new wounds forming and/or coalescing. While the enrollee is noted to apply dressings and wear Cam walking boots, it is unclear how well the enrollee is controlling his diabetes and off-loading his feet. Because there is no evidence of a single, persistent ulcer, which has not responded to therapy, the requested skin substitute is not shown to be medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Puraply Skins substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve Puraply Skins substitute.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on October 24, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the
orthoses were medically necessary. The Plan denied your request. The Plan says documentation submitted did
not indicate the provider discussed the need for the orthoses.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The ordering physician's office visit notes do not support medical
necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee
orthoses (L1833) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does
not have to pay for the knee orthoses and suspension sleeves provided on October 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee arthroscopy (29881)
You asked the Plan to pre-approve knee arthroscopy. You say that you would like reconsideration because you are unable to walk and therapy is too painful. The Plan denied your request. The Plan says the records do not show that you have a tear in in meniscus, a healthy BMI or have tried conservative treatment.
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 knee arthroscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical literature would not support this surgical request in the absence of imaging evidence of meniscal pathology or chondral defect, lack of physical exam evidence confirmatory for meniscal tear and lack of a reasonably detailed and recent failure of conservative treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee arthroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve knee arthroscopy (29881)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from
December 3, 2019 to December 5, 2019.
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you should only be
charged for one inpatient day. The Plan denied your request. The Plan says you have been charged the correct
cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350
copayment for each day, day(s) 1-5 for inpatient hospital care.
You have been asked to pay a $350 copayment for each day of the inpatient hospital stay. ($350 x 2 days =
$700). The 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. The medical record shows
you were admitted as an inpatient on December 3 and were discharged on December 5, 2019.
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 inpatient hospital stay provided from
December 3, 2019 to December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound preparation services provided on December 3, 2019.
You asked the Plan to pay for the services at issue. The Plan denied your request. The Plan says the code description was not documented in the report narrative. The billed services cannot be verified.
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 15004 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services at issue. Our physician reviewer found that the enrollee had a lesion on his scalp. According to the operative report, a different surgeon removed/excised the lesion, thereby creating the wound. The appellant surgeon then debrided the wound edges before placing the graft. It is difficult to call the debridement of the wound edges an excision, when done immediately after someone else excised the lesion and created the wound. As such, the billing of CPT 15004 is not supported. 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 at issue have not been met. Therefore, we decided that the Plan does not have to pay for wound preparation services provided on December 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for eye surgery provided on October 18, 2019.
You asked the Plan to waive the copayment for eye surgery. You say that you saw your doctor for a regular
visit and had the procedure the same day. You say that you don't understand why you need to pay. 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 $75 per
day for outpatient procedures and services, including, but not limited to, outpatient surgery performed in an
outpatient hospital or ambulatory surgical center.
You have been asked to pay a $75 copayment for the eye surgery. The eye surgery 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 eye surgery provided
on October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a gym membership with provider, on November 25, 2019.You asked the Plan to reimburse you for the gym membership. You say that you paid your 2020 gym membership early. The Plan denied your request. The Plan says the date of service for this benefit is the date you make payment. The Plan paid the $240 reimbursement on January 30, 2019.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because the paid the $240 reimbursement on January 30, 2019.The date of service for this benefit is the date you make the payment. The file shows you made a payment on November 25, 2019. Therefore, we decided that the Plan does not have to reimburse you for a gym membership with provider, on November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction to be performed by an oral surgeon.
You asked the Plan to pre-approve the dental service. You say that you were in the hospital from February 14, 2020 to February 18, 2020 because of your teeth. You say that you keep getting infections and have to keep taking antibiotics. You say that it is affecting your health. You also say that you need to get your teeth removed so that you can stop getting infections. The Plan denied your request. The Plan says services must be performed by a participating general dentist.
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 and extractions are a covered service, they must be performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction to be performed by an oral surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Stelara injections provided on April 4, 2019 and July 25, 2019. You asked the Plan to waive the coinsurance for the injections. You say that you did not believe you would be charged for these injections. The Plan denied your request. The Plan says that you are responsible for the cost sharing. 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 chemotherapy and other drugs covered by Medicare Part B. You have been asked to pay a 20% coinsurance for the injections. The injections fall within the chemotherapy and other drugs covered by Medicare Part B 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 Stelara injections provided on April 4, 2019 and July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

Explanation of decision
We decided that the Plan does not have to waive the copayment for an office visit provided on November 8, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you should not be responsible for
an additional office visit. 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 $10
copayment for physician/practitioner services/PCP.
You have been asked to pay a $10 copayment for an office visit. Since an office visit was provided the correct
copayment has been applied. An office visit falls within the physician/practitioner services/PCP 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 office visit provided on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean office visit (99212), duplex scan (93971), and ablation therapy (36478) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvean OON office visit, duplex scan, and ablation therapy. You say that the enrollee needs this treatment.The Plan denied your request. The Plan says these services are available from in-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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvean office visit (99212), duplex scan (93971), and ablation therapy (36478) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the specialist services rendered to you on October 18, 2019.You asked the Plan to waive the deductible for these services. You say that the website says the cost is $45.The Plan denied your request. The Plan says the deductible was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $250 yearly deductible for covered in-network medical services. The item or service you asked the Plan to waive the deductible for falls within the in-network Medicare-covered visit with a specialist benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $250 yearly deductible for covered in-network medical services. This cost sharing is a contractual obligation that had not been met at the time these services was received on October 18, 2019. The $45 copayment does not apply until after you have met the yearly deductible. Therefore, we decided that the Plan does not have to waive the deductible for the specialist services rendered to you on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hospital services
You asked the Plan to waive the copayment for hospital services. You say that you should only have to pay for an emergency room visit. 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 $600 copayment for outpatient hospital services/in-network/outpatient hospital and observation service. You have been asked to pay a $600 copayment for hospital services. Observation services were provided; therefore, the correct copayment has been applied. Hospital services fall within the outpatient hospital services/in-network/outpatient hospital and observation service 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 hospital services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) for the enrollee.
You asked the Plan to pre-approve a CGM. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates the enrollee is not treated by insulin injections three or more times a day or testing his blood glucose four or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) for the enrollee.