Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to adjust the copayment. We decided that the Plan does not have to waive the copayment.

You asked the Plan to waive the copayment. The Plan says that you are responsible for the copayment.

We decided that the Plan has to adjust the copayment.

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 $50 copayment for days 1-8, and a $0 copayment for days 9-90, for inpatient mental health care.

The Plan says you must pay a $900 copayment for the inpatient mental health care. Based on the Plan contract, however, you cannot be asked to pay more than $50 per day for days 1-8 for inpatient mental health care, totaling $400. Therefore, we decided that the Plan has to adjust the copayment for the inpatient mental health services.

We also decided that the Plan does not have to waive the copayment.

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 $50 copayment for days 1-8 for inpatient mental health care. 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 mental health services you received.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you need LTACH care for your medical
condition. The Plan denied your request. The Plan says LTACH care is not medically necessary at this time.
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 LTACHs do not provide clinical services that are materially different than those of
short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not
been denied. The documentation does not support that the enrollee in this case requires services at the LTACH
that are not available at the acute care hospital where he is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder brace (L3960) provided on August 18, 2020.
You asked the Plan to pay for shoulder brace. You say that the item is medically necessary. The Plan denied
your request. The Plan says there is insufficient documentation indicating the medical necessity of the item
provided.
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 pay for shoulder brace. Our reviewer says that the
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found
a physical examination of the shoulder would reasonably be required to adequately assess whether the
shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the
orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient
documentation of a credible physical examination of the shoulder.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of shoulder brace have not been met. Specifically, there is insufficient
documentation of a credible physical examination of the shoulder. This means the item provided is not
medically necessary or reasonable. Therefore, we decided that the Plan does not have to pay for shoulder brace
(L3960) provided on August 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the ambulance services provided on June
29, 2020.
You asked the Plan to waive the cost-sharing for the ambulance services. You say that you have never had a
copayment before. The Plan denied your request. The Plan says the claim was processed accordingly with your
2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received the ambulance services provided on June 29, 2020. You were asked
to pay a $90 copayment for the ambulance services. Your 2020 EOC states that enrollees must pay a $90
copayment for Medicare-covered ambulance services per day. 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 cost-sharing
for the ambulance services provided on June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bridge from tooth 22 to 20.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
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 these services
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found there does appear to be sufficient
supporting bone to allow for fixed or removable appliances in the submitted documentation. The Plan provides
that fixed prosthodontics are only considered in cases where there is a physical or neurological deficit that
prevents use of a removable appliance. In this instance, there has been no submission of documentation to
support any claim of physical or neurological disorder that would preclude the use of a removable appliance.
Given the Plan limitations on fixed prosthodontics, there would be no necessity for the cantilever bridge that is
being requested.
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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a bridge from tooth 22 to 20.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by a non-contracted 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 a non-contracted 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 by a non-contracted provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a diagnostic test provided by a participating provider on October 13, 2020.
You asked the Plan to waive the deductible for a diagnostic test. You say that you have never had to pay for this before. The Plan denied your request. The Plan says the correct deductible has been applied.
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 a $250 deductible for outpatient diagnostic tests/diagnostic test. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests/diagnostic test. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for outpatient diagnostic tests/diagnostic test. This cost sharing is a contractual obligation that had not been met at the time a diagnostic test was received on October 13, 2020. The total amount you are being asked to pay is $46.82. Deductibles are applied to diagnostic tests/procedures. Therefore, we decided that the Plan does not have to waive the deductible for a diagnostic test provided by a participating provider on October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lens fitting provided on August 11, 2020.
You asked the Plan to pay for the contact lens fitting. You say that this should be covered because it was
covered the previous year. The Plan denied your request. The Plan says that this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and
eyewear.
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we
decided that the Plan does not have to pay for the contact lens fitting provided on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic test provided by a participating
provider on September 15, 2020.
You asked the Plan to waive the copayment for a diagnostic test. You say that normally patients are encouraged
to be preventative. 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 $65
copayment for outpatient diagnostic /outpatient diagnostic procedure or test.
You have been asked to pay a $65 copayment for a diagnostic test. Since a diagnostic test was provided, the
correct copayment has been applied. A diagnostic test falls within the outpatient diagnostic /outpatient
diagnostic procedure or test 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 a diagnostic
test provided by a participating provider on September 15, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 23, 2020, to September 26, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this inpatient stay is correct, because this readmission was within 30 days of the index admission and readmission was preventable.
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. Readmission review is based on whether a hospital has misrepresented admission or discharge information, or has taken an action that results in unnecessary multiple admissions of an individual. 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 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 this hospital readmission was medically necessary. The readmission did not result from a premature discharge from the same hospital. The enrollee's partial small bowel obstruction was resolved at the time of the previous discharge by symptoms. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 23, 2020, to September 26, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 physical therapy (PT) visits.
You asked the Plan to pre-approve 2 PT visits. 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. The rules say that Medicare pays for medically necessary outpatient therapy. 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 2 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found the additional 2 requested therapy sessions are not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You were approved 8 outpatient visits of therapy and the records do not demonstrate that your deficits require the ongoing unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist beyond the approved therapy. You can be instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 2 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the oral exam (D0120), the surgical extraction
(D7210), and the bone replacement graft for ridge preservation (D7953) provided from October 1, 2020, to
October 15, 2020.
You asked the Plan to pay more for the dental services. You say that you were billed $115 for the oral exam
and $505 for the surgical extraction. You say that you were told by the plan that oral exams are covered 100%
and the extraction would be covered at 50% in network. You say that you did not know that they can charge
you anything they wanted. You say that you were told the provider was in network. You also say that you were
told the bone graft was a medically necessary service. The Plan denied your request. The Plan says the provider
in this case is out of network. The Plan says that out of network providers are allowed to bill the difference of
the allowed amount and their billed amount to you. The Plan says that bone replacement graft for ridge
preservation is not listed as a covered service.
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, out of network providers are allowed
to bill you for the difference of the allowed amount and their billed amount. The record shows that the plan
paid 100% of the allowed amount for the comprehensive oral evaluation. The Evidence of Coverage says you
pay a 50% coinsurance for major dental services, including surgical extractions. The record shows that the Plan
paid 50% of the allowed amount for the surgical extraction. Additionally, the bone replacement graft is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay more for the
oral exam (D0120), the surgical extraction (D7210), and the bone replacement graft for ridge preservation
(D7953) provided from October 1, 2020, to October 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the home ventilator. You say that you refuse for the enrollee to use an in-network provider. The Plan denied your request. The Plan says there are in network alternatives available.
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-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four simple extractions provided on July 29, 2020.
You asked the Plan to pay for the extractions. You say that the extractions were required prior to operating for a valve replacement. The Plan denied your request. The Plan says these services are not covered benefits.
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 four simple extractions provided on July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided March 1, 2020 to March 31, 2020.
You asked the Plan to waive the copayment for the SNF services. You say that due to the COVID 19 virus lockdown, the enrollee had to remain in the nursing facility longer than necessary. Now you are being charged copayment for additional days that he didn't have to be there. The Plan denied your request. The Plan says the plan corrected the copayment for the SNF services according to the Evidence of Coverage and the maximum out of pocket.
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 $0 copayment per day for days 1-20, $178 copayment per day for days 21-100 for Skilled nursing facility (SNF) care. You have been asked to pay $1811.22 copayment for the SNF services. Your maximum out of pocket is $3,400. As you had met $1588.78 the amount of $1811.22 applies to your maximum out of pocket. The SNF services falls within the Skilled nursing facility (SNF) 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 skilled nursing facility (SNF) services provided March 1, 2020 to March 31, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy and biopsy with removal of polyps or growths (45385, 88305, 45380) provided October 16, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that your colonoscopy should be considered a screening colonoscopy. The Plan denied your request. The Plan says the service provided was considered a diagnostic colonoscopy and the copayment was 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 $225 copayment for Medicare-covered outpatient surgery performed in a hospital or ambulatory surgical center. You have been asked to pay a $225 copayment for the colonoscopy. In this case, the colonoscopy was performed due to a medical history of colonic polyps and additional polyps were removed during the procedure. The colonoscopy is therefore considered diagnostic. This service falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 colonoscopy and biopsy with removal of polyps or growths (45385, 88305, 45380) provided October 16, 2020.