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

We decided that the Plan does not have to waive the deductible and coinsurance for a specialist visit provided on January 25, 2021.

You asked the Plan to waive the deductible and coinsurance for a specialist visit. You say that you feel that the charges are too high. 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. Your contract with the Plan says that there is a $290 deductible. Your contract with the Plan also clearly says that after the $290 deductible has been met, enrollee's are also responsible to pay 20% coinsurance for specialist services. 

You had a specialist visit on January 25, 2021. The record shows that you had paid $0 toward the $290 deductible prior to receiving the services. Therefore, you are responsible to pay the $290 deductible. Now that the deductible has been met, you are also responsible to pay 20% coinsurance on the difference between the total allowed amount and the deductible amount. $631.95 (allowed amount) - $290 (deductible) = $341.95 and 20% of that is $68.39.

The total amount you owe is: $358.39.

The item or service you asked the Plan to waive the deductible and coinsurance for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $290 deductible for physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time a specialist visit was received on January 25, 2021. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance for a specialist visit provided on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on February 25, 2021 by an OON provider.
You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that the Plan's literature regarding dental treatment states there is a $0 copay for dental preventative and comprehensive services, up to $1,000 per year. The Plan denied your request. The Plan says the total liability amount of $134.00 was applied correctly. The Plan also says that the member liability is a contractual obligation under the Plan and cannot be waived.
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 the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on February 25, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for vision services provided by a participating provider on January 21, 2021.
You asked the Plan to waive the deductible for vision services. You say that you have never had to pay this much before. The Plan denied your request. The Plan says the correct deductible amount 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 $203 deductible for vision services. The item or service you asked the Plan to waive the deductible for falls within the benefit category vision services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible for vision services. This cost sharing is a contractual obligation that had not been met at the time vision services was received on January 21, 2021. The total amount you are being asked to pay is $188.48. Therefore, we decided that the Plan does not have to waive the deductible for vision services provided by a participating provider on January 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on December 4, 2020.

You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the item at issue is not medically necessary.

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 a lumbar-sacral orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible physical examination of the back. 

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on December 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites (D2331 and D2392) provided on February 26, 2021.
You asked the Plan to pay for the resin-based composites. You say that the dental office told you that the amount of $1,000 per year was covered. You also say that you were not advised that the Plan only paid every three months. The Plan denied your request. The Plan says the maximum allowed for the quarterly maximum has been met.
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 Plan offers up to a $375.00 allowance for covered comprehensive dental services every quarter. The record shows that your maximum allowance of $375.00 for the first quarter of the 2021 plan year was met for services completed on February 10, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composites (D2331 and D2392) provided on February 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the left knee (73721).
You asked the Plan to pre-approve an MRI. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the documents doe no support medical necessity of the requested service.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for left knee MRI (73721) is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the left knee (73721).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the Coronavirus test provided on October 19, 2020.

You asked the Plan to pay for the Coronavirus test. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to
the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the Coronavirus test provided on October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) and adjunctive procedure (D9999) provided on December 22, 2020.

You asked the Plan to pay for the re-cement or re-bond crown and adjunctive procedure. You say that the enrollee's existing crown came off and you re-cemented it. You also say that you feel this claim was denied in error. The Plan denied your request. The Plan says the enrollee does not have mandatory or supplemental dental coverage with the Plan so these services are not covered under Medicare or the enrollee's plan under any condition.

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 the enrollee's teeth or the structures directly supporting the enrollee's 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 re-cement or re-bond crown (D2920) and adjunctive procedure (D9999) provided on December 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart failure. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on March 19, 2021.

You asked the Plan to pay for the provided items. You say that telemedicine modalities are allowed. The Plan denied your request. The Plan says documentation to validate an established relationship was not provided.

The Plan follows Medicare rules. Medicare rules say that the medical record must contain sufficient documentation of the medical condition to substantiate the necessity.

We looked at the file and Medicare rules. There are insufficient medical records to substantiate the knee orthosis. The record provided appears to be a phone conversation with the enrollee presenting her problems. The records do not include previous physical exams, testing, or imaging to confirm a diagnosis or condition. There are no medical records that show a trial of conservative measures. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on March 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on February 24, 2021.

You asked the Plan to pay for the dental service. You say that you have been requesting this procedure for many months due to your health. You say that your dentist has repeatedly told me it was better to keep your teeth. You say that due to your illness, your teeth keep chipping and wearing down. You also say that you need your bottom teeth removed so you can get dentures. The Plan denied your request. The Plan says 1 oral exam is covered every 6 months. The Plan also says that the frequency limit 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 and oral exams are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for an oral exam that you received on November 19, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated scooter.

You asked the Plan to pre-approve a power operated scooter. You say that this device is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated scooter.
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 due to your current illnesses and medical needs, you feel you would be better served at an LTACH during your prolonged hospital admission. The Plan denied your request. The Plan says you are currently receiving appropriate care and an LTACH would not provide a clinical advantage.
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 there is no documentation provided demonstrating medical necessity for LTACH services. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available and covered at the acute care hospital where you are currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the CT scan and self-administered drugs provided from March 28, 2021, through April 1, 2021.
You asked the Plan to waive the cost for the CT scan and self-administered drugs. You say that you were treated poorly for three days and given a drug you were allergic to. You say that insurance should honor you being admitted. The Plan denied your request. The Plan says the claim reprocessed 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 advanced imaging services from a network provider. You have been asked to pay a $225 copayment for the CT scan and $34.73 for the self-administered drugs. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. 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.
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 for the CT scan and self-administered drugs provided from March 28, 2021, through April 1, 2021.
Benefits for the self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF is the best option for this enrollee to return home quickly and in the best condition. The Plan denied your request. The Plan says the criteria for an IRF admission are not met. The necessary services can be provided in a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation (A0429, A0425) provided on February 5, 2021.

You asked the Plan to waive the copayment for emergency ambulance transportation. You say that you want the Plan to pay for the service at issue. The Plan denied your request. The Plan says 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 $50 copayment for ambulance services.

You have been asked to pay a $50 copayment for emergency ambulance transportation. The service at issue falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency ambulance transportation (A0429, A0425) provided on February 5, 2021.