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

We decided that the Plan does not have to waive the copayment for the SNF stay provided from January 1,
2020 through January 18, 2020.
You asked the Plan to waive the copayment for the SNF stay. You say that you wanted to stop services at day
20 because you didn't want to pay. You say that you were informed you were approved for longer. 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 a $0
copayment per day per admission for days 1-20 and a $178 copayment per day per admission for days 21-100
at an in-network provider.
You have been asked to pay a $712 copayment for the SNF stay.
The SNF stay 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 SNF stay provided from January 1, 2020 through January 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-sterile gloves.
You asked the Plan to pre-approve non-sterile gloves. You say that your doctor recommended non-sterile gloves for health reasons. The Plan denied your request. The Plan says non-sterile gloves are not intended to treat a condition and are non-reusable disposable items.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Medicare only covers disposable gloves for home dialysis patients. Therefore, we decided that the Plan does not have to pre-approve non-sterile gloves.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided on January 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that you were not aware a prior authorization was needed. The Plan denied your request. The Plan says you do not have OON benefits.
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 has network providers available who can provide 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 OON services. Therefore, we decided that the Plan does not have to pay for the ophthalmology services provided on January 17, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the speech therapy visits provided from February 14, 2020 to March 30, 2020.
You asked the Plan to waive the copayments for the speech therapy visits. You say that no one told you a copayment would apply or that the copayment would be that high. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $25 copayment for physical therapy, occupational therapy and speech therapy at an outpatient hospital setting. The enrollee has been asked to pay a $25 copayment for each of the speech therapy visits. The speech therapy visits fall within the "Outpatient rehabilitation services" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the speech therapy visits provided from February 14, 2020 to March 30, 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. You asked the Plan to pre-approve IRF care. 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 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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met at a lower 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the breast localization device placement provided on January 14, 2020.
You asked the Plan to waive the deductible for the breast localization device placement. You say that you already met your deductible. The Plan denied your request. The Plan says the deductible applied correctly.
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 your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Outpatient surgery isn't excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the breast localization device placement was received on January 14, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the breast localization device placement provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4), drugs or medicaments dispensed in the office for home use (D9630 x2), and four periodontal scaling and root planings (D4341 x4) provided on June 24, 2019.
You asked the Plan to pay for the gingival irrigations, drugs or medicaments dispensed in the office for home use, and scaling and planings. You say that this provider was supposed to do a regular cleaning but did a deep cleaning instead. The Plan denied your request. The Plan says gingival irrigation and drugs or medicaments dispensed in the office for home use are not covered by the Plan. The Plan also says that the maximum allowed for scaling and planing limitation 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, gingival irrigation and drugs or medicaments dispensed in the office for home use are not among those covered under this benefit. The contract also says that periodontal scaling and root planing is limited to 1 deep cleaning every 2 years per quadrant. The record shows that you received periodontal scaling and root planings on August 20, 2018 and August 27, 2018 and your periodontal scaling and root planing benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4), drugs or medicaments dispensed in the office for home use (D9630 x2), and four periodontal scaling and root planings (D4341 x4) provided on June 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LenSx Laser Cataract Surgery.
You asked the Plan to pre-approve LenSx Laser Cataract Surgery. You say that the service is necessary because the provider advised you this was the most accurate and up to date procedure. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 LenSx Laser Cataract Surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare provides coverage for cataract removal and insertion of a conventional intraocular lens. The documentation does not support that the LenSx laser cataract surgery is medically reasonable and necessary for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of LenSx Laser Cataract Surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve LenSx Laser Cataract Surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve referral for services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 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 referral for services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient mental health visits provided from January 17, 2020 to February 14, 2020.
You asked the Plan to waive the cost share for the outpatient mental health visits. You say that you are appealing these charges. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $198 deductible that applies towards outpatient mental health care visits and a $20 copayment for outpatient mental health care. The outpatient mental health care visits you asked the Plan to waive the cost share for falls within the "Outpatient mental health care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible that applies towards outpatient mental health care visits and a $20 copayment for outpatient mental health care. This cost sharing is a contractual obligation that had not been met at the time the outpatient mental health visits were received on January 17, 2020 to February 14, 2020. Therefore, we decided that the Plan does not have to waive the cost share for the outpatient mental health visits provided from January 17, 2020 to February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visits provided from January 16,
2020 through January 20, 2020.
You asked the Plan to waive the copayment for the office visits. You say that these should be reprocessed as
hospital claims with no copayment. The Plan denied your request. The Plan says the copayments 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 $45
copayment for provider and professional services at an in-network specialist's office.
You have been asked to pay a $45 copayment for each office visit. The total amount you owe is $225 ($45/
visit x 5 visits = $225). The office visits fall within the "Physician/Practitioner services, including doctor's
office visits" benefit category. The records show that the office visits were billed by a specialist. This means
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for the office visits provided from January 16, 2020 through January 20,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lower leg compression system
application and wound debridement provided on January 7, 2020 through January 27, 2020.
You asked the Plan to waive the copayment for the lower leg compression system application and wound
debridement. You say that you received wound care not minor surgery. You say that you shouldn't have to pay
for an operating room. 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 a $150
copayment for each Medicare-covered outpatient hospital facility visit.
You have been asked to pay a $150 copayment for the lower leg compression system application and wound
debridement provided from January 7, 2020 through January 27, 2020.
The lower leg compression system application and wound debridement fall within the "Outpatient Surgery,
including services provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit
category. The lower leg compression system application and wound debridement are considered surgical
services.
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 lower leg compression system application and wound
debridement provided on January 7, 2020 through January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274),
comprehensive periodontal evaluation - new or established patient (D0180) and 2D oral/facial photographic
image obtained intra-orally or extra-orally (D0350) provided on February 12, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the services are not covered.
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.
You exhausted your benefit frequency limit for the bitewings - four radiographic images (D0274) because this
service was already provided before this date of service. Your EOC states, one (1) procedure per plan year for
D0274. Furthermore, comprehensive periodontal evaluation - new or established patient (D0180) and 2D
oral/facial photographic image obtained intra-orally or extra-orally (D0350) are not listed in your EOC as
covered benefits. Therefore, we decided that the Plan does not have to pay for bitewings - four radiographic
images (D0274), comprehensive periodontal evaluation - new or established patient (D0180) and 2D
oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided on February 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the urinary catheter and lubricant provided
on January 30, 2020.
You asked the Plan to waive the coinsurance for the urinary catheter and lubricant. You say that the bladder
problems are due to the loss of blood in the lower extremities. You say that it wasn't your fault so you shouldn't
have to pay anything. The Plan denied your request. The Plan says the coinsurance 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 20%
coinsurance for prosthetic devices and medical supplies.
You have been asked to pay a total of $62.89 for the urinary catheter and lubricant.
The urinary catheter and lubricant fall within the "Prosthetic device sand 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 the urinary catheter and lubricant provided on January 30,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on December 21, 2019 by
an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were medically necessary.
You say that the referring provider was in-network. The Plan denied your request. The Plan says no prior
authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide 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 skilled nursing services provided on December 21,
2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 74018 and 71045 provided on
November 29, 2019.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes
74018 and 71045 for the x-ray services have a bundled relationship with code 74022 and cannot be paid as
billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria
have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 74018
and 71045 provided on November 29, 2019.
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 a LTACH admission is medically
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for
coverage of a LTACH admission.
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 that the enrollee was admitted to the acute care hospital with shortness of breath. He
required sedation, intubation, and vasopressors. A tracheostomy was placed on June 5, 2020. A PEG tube was
placed on June 13, 2020. Antibiotics are being administered for a diagnosis of pneumonia. The enrollee
continues on an IV vasopressor and does not have an acceptable cardiovascular status for transfer. 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. There are no required medical services
identified that are available at the LTACH, that are not available at the current health care setting being offered
by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for
the diagnosis and condition of the enrollee at this time.
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.