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

We decided that the Plan does not have to waive the copayment for emergency care provided from October 21, 2020, to October 23, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because you were admitted to the hospital and were told you would 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 $90 copayment for emergency care. You received emergency care from October 21, 2020, to October 23, 2020. The record shows that you were admitted under observation. Please note, this is cheaper than if you were admitted inpatient and is in your financial favor. Therefore, you are responsible to pay the $90 copayment. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided from October 21, 2020, to October 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from October 29, 2020, through November 4, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that this was not an inpatient hospital stay and should be reprocessed as a skilled nursing facility. 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 $375 per day, days 1-5 and $0 for additional hospital days for each Medicare-covered hospital admission at an in-network provider. You have been asked to pay $1,875 for the inpatient stay. ($375/day x 5 days = $1,875). The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show this was an inpatient stay. 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 stay provided from October 29, 2020, through November 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a shoulder orthosis (L3660) provided on December 15, 2020.
You asked the Plan to waive the coinsurance for a shoulder orthosis. You say that it strikes you as wrong that the requested item is classified and priced as it is. The Plan denied your request. The Plan says the correct coinsurance was 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 10% coinsurance for covered items of durable medical equipment and related supplies. You have been asked to pay $9.80, or 10% of the Medicare-allowed amount of $98.00, for a shoulder orthosis. A shoulder orthosis 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 a shoulder orthosis (L3660) provided on December 15, 2020.
Your complaint about how the price of your durable medical equipment is determined is not a valid appeal 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 pay for a medical eye exam provided on November 16, 2020.
You asked the Plan to pay for the medical eye exam. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, the enrollee must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, 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 a medical eye exam provided on November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and two additional intraoral periapical x-rays provided on December 14, 2020.
You asked the Plan to pay for the comprehensive oral evaluation and additional intraoral periapical x-rays. You say that you believe these services should be covered. The Plan denied your request. The Plan says benefits for these services have been satisfied and the frequency limitations have 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, comprehensive oral evaluation is limited to one procedure every three years and intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a comprehensive oral evaluation on January 23, 2020, and a first intraoral periapical x-ray on December 14, 2020, and your comprehensive oral evaluation and intraoral periapical x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and two additional intraoral periapical x-rays provided on December 14, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on November 2, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you should not have a copayment for a mammogram. The Plan denied your request. The Plan says you were charged this copayment correctly for an ultrasound.
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 $100 copayment for Outpatient Diagnostic ultrasound. You have been asked to pay a $93.54 copayment for the ultrasound. The ultrasound falls within the Outpatient Diagnostic ultrasound benefit category. The allowed amount for this procedure is $93.54, which is less than your copayment.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 ultrasound provided on November 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on August 12, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.
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 looked at the file, and Medicare rules. The denied codes remain not supported. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglass fitting (92341) provided on October 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the eyeglass fitting. You say that the provider did not know their network status in relation to the enrollee. The Plan denied your request. The Plan says the services obtained are out-of-network and no referral was provided by an in-network 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 the eyeglass fitting (92341) provided on October 15, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from October 10, 2020, through October 13, 2020.
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says the services were provided out-of-network and were not prior authorized 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 did not pre-approve the inpatient admission. 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 inpatient admission provided from October 10, 2020, through October 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan (78815).
You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary. The Plan denied your request. The Plan says coverage rules are not met.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 PET scan. Our reviewer says that the PET scan is not medically necessary. Our physician reviewer found there is no diagnosis of cancer and cancer is not strongly suspected. A PET scan is not appropriate. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan (78815).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that these orthotics are needed for foot support due to poor circulation of blood. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammogram provided on December 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for mammogram. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating 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 a mammogram provided on December 23, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair.
You asked the Plan to pre-approve a group 3 power wheelchair. You say that the requested group 3 power wheelchair is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested group 3 power wheelchair (K0861).
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 a group 3 power wheelchair. Our reviewer says that the enrollee does not meet criteria for the requested group 3 power wheelchair (K0861). Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the above Local Coverage Determination (LCD): Power Mobility Devices (L33789) criteria for the requested group 3 power wheelchair (K0861). The enrollee's mobility limitation is not documented to be due to a neurological condition, myopathy, or congenital skeletal deformity. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 3 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on October 24, 202, to October 29, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with this copayment. 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 $170 copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient hospital care. You have been asked to pay a $170 copayment per day for days 1-5 for an inpatient hospital stay. The total amount you are being asked to pay is $850 ($170 x 5 days = $850). An 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. 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 inpatient hospital stay provided by a participating provider on October 24, 202, to October 29, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on August 17, 2019.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.

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 services was not filed until January 5, 2021. 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 services provided on August 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on November 2, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 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 services provided to you by an out-of-network provider on November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the crown for tooth #19. We decided that the Plan does not have to pre-approve the crown for tooth #18.
You asked the Plan to pre-approve the crown for tooth #'s 18 and 19. You say that you believe the crowns were denied due to the angle of the periapical x-ray. You also say that the bitewing x-ray should be considered for the recommended treatment. The Plan says that there does not appear to be significant breakdown to the tooth, and the documentation does not demonstrate that there is pathologic destruction to the tooth.
We decided that the Plan has to pre-approve the crown for tooth #19.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown for #19 when the services are medically necessary and reasonable. 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 crown for #19. Our reviewer says that the crown for #19 is considered medically necessary. Our physician reviewer found the provided x-rays show tooth #19 with clearly more than three involved surfaces with a very large multi surface restoration that involves the distal cusps. Our reviewer also found that the tooth has recurrent decay and qualifies for a crown restoration under the Plan criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown for #19 have been met. Therefore, we decided that the Plan has to pre-approve the crown for tooth #19.
We also decided that the Plan does not have to pre-approve the crown for tooth #18.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown for #18 when the services are medically necessary and reasonable. 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 crown for #18. Our reviewer says that the crown for #18 does not meet criteria for crowns. Our physician reviewer found tooth #18 has a large three surface restoration with recurrent decay, but should be restorable with a conventional restoration. Our reviewer also found that there is no sub-crestal caries so the teeth would be considered restorable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown for #18 have not been met. Therefore, we decided that the Plan does not have to pre-approve the crown for tooth #18.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for exercise equipment (A9300) purchased on March 25, 2020.
You asked the Plan to pay for exercise equipment. You say that you purchased the requested item when the pandemic began in March of 2020, knowing that you would not be able to go outside for a while. The Plan denied your request. The Plan says rules for payment have not been met.
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 covers exercise equipment only under an emergency declaration related to the COVID-19 pandemic. The coverage is effective for purchases made between October 1 and December 31, 2020. The Plan's rules for coverage of exercise equipment have not been met because the requested item was purchased before October 1, 2020. Therefore, we decided that the Plan does not have to pay for exercise equipment (A9300) purchased on March 25, 2020.