Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on October 8, 2020.

You asked the Plan to waive the copayment for an office visit. You say that this was your annual wellness exam and you should not owe a copayment. 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 $10 copayment for each primary care provider visit. 

The medical records show that you received services beyond an annual wellness exam on October 8, 2020. Therefore, you are responsible to pay the $10 copayment. 

You have been asked to pay a $10 copayment for an office visit. An 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 an office visit provided on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam provided on October 1, 2020.

You asked the Plan to pay for the eye exam. The Plan denied your request. The Plan says prior authorization was not obtained.

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 an eye exam provided on October 1, 2020.
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 this transfer is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are 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 you were admitted to the current acute care facility with recent hospitalization for surgical intervention of retroperitoneal rectal perforation for rectal cancer and was transferred for hyperbaric oxygen therapy and ongoing care including multiple wound care. The records show you are currently stable. Your course of care can be safely provided in the current setting. There are no services at the long-term care facility that are not already available and covered at the current facility. Medicare coverage criteria for transfer are not 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 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: Favorable

We decided that the Plan has to waive the copay for the vision services provided on October 13, 2020.

You asked the Plan to waive the copay for the services provided. You say that you are eligible for one eye exam covered at 100% per year. The Plan denied your request. The Plan says that the copay applied appropriately.

The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that you pay nothing for Medicare-covered services. 

The file shows that you received a complete eye exam and eye refraction services. You have been asked to pay a $10 copay for the services provided. The services fall within the vision care benefit category. This means that you do not have to pay a $10 copay based on your contract with the Plan. Therefore, we decided that the Plan has to waive the copay for the vision services provided on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

You asked the Plan to pre-approve the bed. You say that you need to be able to raise your legs. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care for the enrollee.

You asked the Plan to pre-approve inpatient mental health care. You say that inpatient mental health care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient mental health care. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the records show the enrollee was admitted to the acute inpatient psychiatric hospitalization on February 17, 2021 with Major Depressive Disorder, Recurrent, Severe with Psychotic Features and Borderline Personality Disorder. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. The enrollee rated her depression as eight out of ten but described being unhappy about going to a nursing facility. The records show the enrollee was smiling brightly and friendly in her demeanor. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others and was compliant with her treatment. The enrollee does not meet the criteria for continued acute inpatient mental health treatment beyond February 26, 2021. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for travel expenses for July 3, 2019, to July 22, 2019 in the amount of $451.26

You asked the Plan to pay for this travel expense. You say that this travel expense should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for this expense which was required by the Plan contract.

Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says that all services related to transplant services require prior authorization. The Plan provided records to show the travel dates provided were not within the date range of your prior approved transplant dates. The dates in question were not pre-approved for travel. Therefore, we decided that the Plan does not have to pay for travel expenses for July 3, 2019, to July 22, 2019 in the amount of $451.26
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transitional care management visit (99496) provided on July 31, 2020 by an out of network (OON) provider.

You asked the Plan to pay for transitional care visit. You say that this service was medically necessary. The Plan denied your request. The Plan says these services were not urgent or emergent, nor were they pre-approved. Services provided out-of-network and outside these circumstances will not be covered by the Plan.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the transitional care management visit (99496) provided on July 31, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on April 4, 2019.

You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that you did not receive proper notice of the enrollee's benefit determination, resulting in the untimely submission of this claim. The Plan denied your request. The Plan says the claim was not received until August 27, 2020, which is after the deadline to submit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the psychiatric diagnostic evaluation was not filed until August 27, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on April 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit for the excision of malignant lesion (11622, 12042) provided November 5, 2020.

You asked the Plan to waive the copayment for the office visit for the excision of malignant lesion. You say that in the past a copay did not apply to these services. The Plan denied your request. The Plan says the copayment was applied correctly for the services performed during a specialist office visit.

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 $30 copayment for each specialist visit for Medicare-covered benefits. You have been asked to pay a $30 copayment for the excision of malignant lesion performed during a specialist office visit. 

This service 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 office visit for the excision of malignant lesion (11622, 12042) provided November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions of teeth # 19, 20, 21, 22, 27, 28, 29, and 30 provided on March 17, 2020.

You asked the Plan to pay for the dental services. You say that your teeth were decayed from the cancer radiation and chemotherapy treatments. You say that you were never advised that you should have these teeth extracted before the radiation treatments. You also say that the extraction of the teeth was not feasible at the time of the surgery. The Plan denied your request. The Plan says the extractions are dental in nature. The Plan says that routine dental service are not covered by Medicare.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the extractions of teeth # 19, 20, 21, 22, 27, 28, 29, and 30 provided on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent for the enrollee.

You asked the Plan to pre-approve Dupixent. You say that Dupixent is medically necessary. The Plan denied your request. The Plan says Dupixent is self-administered and is not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent for the enrollee.

Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5257) provided on August 20, 2020.

You asked the Plan to pay for the hearing aids. You say that you would like reconsideration because you are using this provider instead of two medical providers which provides you with better professional attention to both hearing and application. The Plan denied your request. The Plan says this hearing aid was not supplied by the Plan's hearing network vendor.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are supplied by the Plan's hearing network vendor. 

We looked at your request, the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, your EOC states that hearing aids are only covered when they are supplied by a Plan hearing network vendor. Th hearing aids at issue were not supplied by the Plan's hearing network vendor. Therefore, we decided that the Plan does not have to pay for hearing aids (V5257) provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, periodontal scalings and root planings, gingival irrigations, and local anesthesia services provided on January 23, 2020, and January 27, 2020 by an OON provider.

You asked the Plan to pay for the problem focused limited oral evaluation, scalings and planings, gingival irrigations, and local anesthesia services. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that services performed by an OON provider are not covered because your healthcare plan does not have OON 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the cost for dental services from an OON provider. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, periodontal scalings and root planings, gingival irrigations, and local anesthesia services provided on January 23, 2020, and January 27, 2020 by an OON provider.
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 this is medically necessary. The Plan denied your request. The Plan says your needs can be met 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 above 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 at the time of discharge from the hospital, you had stabilized medically. You have received home health rehabilitation services with minimal improvement due to a lack of motivation and participation. Your current functional status does not require daily inpatient rehabilitation services. You are not expected to make measurable gains within a reasonable and predictable period of time. You do not require skilled therapy to prevent deterioration of your mobility or activities of daily living. You do not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you do not require any skilled services on an inpatient basis at a SNF level of 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services that you provided from January 13, 2020, through
June 9, 2020.

You asked the Plan to pay for the psychotherapy services The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.

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 psychotherapy services that you provided from January 13, 2020, through June 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an X-Ray examination and Computed Tomography (CT) scan provided on August 28, 2020.

You asked the Plan to waive the copayments for X-Ray and CT scan. You say that the cost-sharing should be waived because these tests diagnosed you with COVID-19. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.

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 $25 copayment for X-Ray examination and $175 copayment for CT scan. Your total copayment obligation is therefore $200. 

You have been asked to pay $25 copayment for X-Ray examination and $175 copayment for CT scan. X-Ray and CT scan fall 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 an X-Ray examination and Computed Tomography (CT) scan provided on August 28, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 13, 2020, through October 20, 2020.

You asked the Plan to pay for the acute inpatient hospital care. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the inpatient hospital care provided was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that you presented to the emergency room (ED) on October 13, 2020 after a fall. You had progressive weakness for two weeks prior to the fall. The computed tomography (CT) scan revealed no acute intracranial event. The magnetic resonance imaging (MRI) of the brain without contrast was significant for a small 9 mm incidental meningioma along the right tentorium without significant mass effect. You had chronic nausea and vomiting which was attributed to gastroparesis. You were treated with Reglan. Outpatient follow up for the mass was recommended. You were admitted to an observation status with plans to place you in a sub-acute rehabilitation facility. On October 15, 2020, you had a baseline left facial droop and a left sided upper extremity weakness. The notes indicated that you were awaiting placement. Your vitals were stable throughout the hospital stay. You were not in renal failure. You were discharged in stable condition on October 20, 2020. 

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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from October 13, 2020, through October 20, 2020.