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

 
We decided that the Plan does not have to reduce the copay for the cystoscopy procedure provided on 
September 4, 2020. 
 
You asked the Plan to reduce the copay for the services provided. You say that you were not aware of the 
copay ahead of time. The Plan denied your request. The Plan says the copay is a contractual obligation. 
 
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 $400 
copay for surgery in an outpatient hospital facility.  
 
You have been asked to pay a $400 copay for the services provided. The services fall within the outpatient 
surgery 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 copay for the cystoscopy procedure 
provided on September 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on September 2, 2020.You asked the Plan to pay forthe 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 September 2, 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 forthe ambulance services provided on September 2, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pulmonary testing services (94726, 94010, 94729) provided on September 14, 2020 by an out of network (OON) provider.You asked the Plan to pay forOON pulmonary testing services. You say that these services were medically necessary.The Plan denied your request. The Plan says these services were 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 networkprovider 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 theseitems/services.Therefore, we decided that the Plan does not have to pay forthe pulmonary testing services (94726, 94010, 94729) provided on September 14, 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 the medical services provided to the enrollee by an out-of-network provider on September 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 6, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the physician depends on the hospital staff to 
obtain proper authorization. The Plan denied your request. The Plan says the services were not urgent, 
emergent or approved in advance. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the medical services provided on August 6, 2020 by an out of network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to be able to navigate before he can return home. You also say that the enrollee needs moderate to maximum assistance with activities of daily living and ambulation. The Plan denied your request. The Plan says the enrollee does not have complex rehab needs that can only be met at an IRF. The Plan also says that the request is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee's medical status does not currently require intensive physician or nursing supervision in an IRF. Our physician reviewer also found that while the enrollee may benefit and participate in multiple therapies, the enrollee's functional level does not require this therapy on an intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on October 6, 
2020. 
 
You asked the Plan to pay for the endodontic therapy. You say that you feel that this service was medically 
necessary and urgently needed. The Plan denied your request. The Plan says this service is not a covered 
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 
endodontic therapy (D3330) provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuropathy treatment provided on September 30, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the neuropathy treatment. You say that given the medical necessity of the treatment provided, you are confident that this admission would have met the criteria for prior authorization. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 neuropathy treatment provided on September 30, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital services provided August 13, 2020 to August 17, 2020.You asked the Plan to waivethe copayment forthe inpatient services. You say that you would like your financial portion for your stay to be covered at 100% or as an alternative, to be reduced to a more fair amount that compensates you for your grievance.The Plan denied your request. The Plan says this claim was processed and the correct copayment has been applied 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 $295 per day, days 1-7 $0 per day, days 8-90 for Inpatient hospital care. You have been asked to pay $1,180.00 ($295 x 4 = $1,180.00) for the inpatient services. The inpatient services fall within the Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe inpatient hospital services provided August 13, 2020 to August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora comprehensive oral examination (D0150) provided on September 23, 2020.You asked the Plan to pay forthe comprehensive oral examination. You say that this service was covered on your original plan. You say that you were not aware that your policy changed for 2020.The Plan denied your request. The Plan says the enrollee hasexceeded the frequency limits set in the subscriber agreement.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 coverage for comprehensive oral examinations is limited to one every three plan years. The records show that you received coverage for a comprehensive oral exam provided on January10, 2019. This means that your benefit for comprehensive oral exams was exhausted on the date of service in dispute.Therefore, we decided that the Plan does not have to pay fora comprehensive oral examination (D0150) provided on September 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
June 25, 2020, through June 30, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you should not have to 
pay this because the provider told you it was paid in full. The Plan denied your request. The Plan says that 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 a $290 
copayment for each day for days 1 to 5 for Medicare-covered hospital care.  
 
You have been asked to pay a $1,450 copayment for the inpatient hospital care. The inpatient hospital care falls 
within the days 1 to 5 for Medicare-covered 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 care provided from June 25, 2020, through June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lead wires rendered on September 29, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that replacement of lead wires (A4557) more often than every 12 months would rarely be reasonable and necessary.We looked at the file and Medicare rules. The file shows that the TENS device was rendered on January 31, 2020; February 29, 2020; and March 29, 2020. Replacement lead wires more often than every 12 months is not necessary.Therefore, we decided that the Plan does not have to pay forthe lead wires rendered on September 29, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe non-emergency ambulance services (A0425, A0428) provided from May 4, 2020, to July 16, 2020.You asked the Plan to pay forthe non-emergency ambulance 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 as required per the EOC.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. The Plan also says that non-emergency ambulance services are only covered when prior authorization is obtained.We looked at fileand Medicare rules. The file indicates that prior authorization was not obtained prior to the non-emergency transport. Based on this information, we decided that Medicare rules for coverage of the non-emergency ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forthe non-emergency ambulance services (A0425, A0428) provided from May 4, 2020, to July 16, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a soundwave test (CPT 93925 and CPT 93970). 
 
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show risk factors for problems with the arteries or veins. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the test. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation specifically notes that you have normal pulses and no edema. It specifically notes that 
there are no vascular issues. There is no discussion in the assessment and plan of any desire to obtain vascular 
imaging studies. 
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a soundwave test (CPT 93925 and CPT 93970).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower denture (D5120) provided.

You asked the Plan to pay for the dental items. You say that the dentures you received in 2019 were very unsatisfactory. You say that they never fit properly despite taking them back several times and even leaving them there to be corrected. You say that when you picked them up, they were the exact same as before. You say that you were advised by a plan representative that you could get another set of dentures this year and they would be covered. You say that you never received a call back from your plan regarding the grievance you filed last year about the dentures you received. You also say that you cannot afford to pay for these dentures.The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan says that the frequency limit for these items has been exceeded.

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 frequency limit of once every 5 years has been exceeded. The record shows that the Plan paid for dentures that you received.Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower denture (D5120) provided.

Your complaints about being misinformed by a plan representative and no one returning your phone calls are not valid appeals for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet joint injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there was insufficient relief from the initial facet joint injection.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that there has not been at least three months of moderate to severe pain that has responded to conservative care. There is no documentation indicating that the pain is not associated with radiculopathy or neurogenic claudication. There is no specific documentation indicating that the facet joint the main source of pain. The initial injection did not produce 80% or more relief. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet joint injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided from April 1, 2019, to April 2,
2019.
You asked the Plan to pay for hospital services. You say that the Plan should pay this claim. The Plan denied
your request. The Plan says the Plan is secondary payer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible
for hospital services until the primary insurer has denied the claim for these services. Therefore, we decided
that the Plan does not have to pay for hospital services provided from April 1, 2019, to April 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 28, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 medical services provided on July 28, 2020 by 
an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe radiological services provided on October 1, 2020.You asked the Plan to waive the copayment forthe radiological services. You say that you would like this copayment waived because your primary care provider suggested this service.The Plan denied your request. The Plan says the copayment has processed correctly in this case.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 $25 copayment for basic radiological services. You have been asked to pay a $25 copayment for the radiological services. The services provided fall within the basic radiological 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 forthe radiological services provided on October 1, 2020.