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

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says there are no complex nursing needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our physician reviewer found that from a nursing perspective, you received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a supervision level with functional mobility. You required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $200 copayment each for ambulance transport provided on April 10, 2020.
You asked the Plan to waive these copayments. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says your copayments were charged based on the service provided and the Plan contract agreement.
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 $200 copayment for each ambulance transport. 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 $200 copayment each for ambulance transport provided on April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy provided by an out-of-network provider
on October 12, 2020.
You asked the Plan to pay for occupational therapy. You say that you were told you would have to wait for the
member to establish as a patient prior to receiving a referral for his therapy. You say that the denial should be
reconsidered based on medical necessity. The Plan denied your request. The Plan says this provider is not a
network provider with the Plan and the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 occupational therapy provided by an out-ofnetwork provider on October 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shoulder arthroscopy (29827), biceps tenodesis (29828), and shoulder tenotomy (23405).
You asked the Plan to pre-approve a shoulder arthroscopy, biceps tenodesis, and shoulder tenotomy. You say that the requested procedures are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested services are 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 pre-approve a shoulder arthroscopy, biceps tenodesis, and a shoulder tenotomy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the case record documents that the enrollee has been working on a guided home exercises program but has not seen any improvements. The medication list does not include nonsteroidal anti-inflammatory drugs (NSAIDs). There is insufficient documentation demonstrating that conservative measures have been tried and failed in this case.
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 shoulder arthroscopy, biceps tenodesis, and a shoulder tenotomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a shoulder arthroscopy (29827), biceps tenodesis (29828), and shoulder tenotomy (23405).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hammertoe repair provided on February 26, 2021.
You asked the Plan to waive the copayment for hammertoe repair. You say that you feel that the surgery should not be considered elective because it was necessary in order for you to walk again. 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You received hammertoe repair at an outpatient hospital facility on February 26, 2021. Hammer toe repair is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $350 copayment. You have been asked to pay a $350 copayment for hammertoe repair. Hammertoe repair 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 hammertoe repair provided on February 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from March 13, 2020, through March 22, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost sharing has been applied correctly to the services provided.
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 $393 copayment for each Medicare-covered day for days 1-5 and a $0 copayment for each additional day; for each inpatient stay.
You have been asked to pay $1,965 ($393 copayment x 5) for the inpatient hospital care provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from
March 13, 2020, through March 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network physician services provided on February 15, 2021.
You asked the Plan to pay for out of network providers. You say that you were not told this provider did not take your insurance. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 out of network physician services provided on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation provided on September 2, 2020.
You asked the Plan to pay for the consultation. You say that you feel you should not be penalized for a service
you were not aware was not covered. The Plan denied your request. The Plan says this service is not covered.
The Plan also says that you did not contact the Plan prior to this date of service to verify benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
consultation provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram reporting (93010) rendered by the
OON provider on February 15, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the electrocardiogram reporting (93010) rendered by the OON provider on February
15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the chest (71046) rendered by the out of network (OON) provider on February 15, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the x-ray exam of the chest (71046) rendered by the out of network (OON) provider on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental evaluation (D0120) and radiographic images (D0220, D0274, D0330) to be received from an out of network dental provider.
You asked the Plan to pre-approve a dental evaluation and radiographic images. You say that you are on certain medications and cannot go to any dental provider. The Plan denied your request. The Plan says rules for dental services have not 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. The Plan covers a dental evaluation and radiographic images when the services are obtained from a provider in the Plan's dental network.
We looked at the file, the Plan contract, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a dental evaluation and radiographic images have not been met. Specifically, the case record indicates that the requested services will be obtained from a provider not in the Plan's dental network. Therefore, we decided that the Plan does not have to pre-approve a dental evaluation (D0120) and radiographic images (D0220, D0274, D0330) to be received from an out of network dental provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) provided on January
8, 2021.
You asked the Plan to pay for the dental service. You say that the services are medically necessary. The Plan
denied your request. The Plan says guided tissue regeneration 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, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
guided tissue regeneration (D4266) provided on January 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested IRF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. 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 the enrollee will be able to fully participate in and benefit from the intensive rehabilitation
therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle.
You asked the Plan to pre-approve a Group 1 power operated vehicle. You say that your current power wheelchair is complicated to control and too heavy to take with you in the car. The Plan denied your request. The Plan says payment is made for only one wheelchair at a time.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a Group 2 standard power wheelchair, provided on March 6, 2020. The Group 2 standard power wheelchair serves the same purpose as a Group 1 power operated vehicle. Your power wheelchair is still under the 5-year reasonable useful lifetime. The evaluation shows your home cannot accommodate a scooter turning radius. Therefore, we decided that the Plan does not have to pre-approve a Group 1 power operated vehicle.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the $240 total copayment charged for physical therapy services provided from March 17, 2020, to March 24, 2020.
You asked the Plan to waive this cost share. You say that you do not believe these copayments are correct because you were being treated in a skilled nursing facility. The Plan denied your request. The Plan says you were provided with physical therapy services. While it is understood that you were in a skilled nursing facility, the records show your skilled nursing facility stay became private pay as of March 15, 2020. The Plan says the Plan contract states there is a $40 copayment for each Medicare covered therapy service. You were provided with physical therapy services from March 17, 2020 through March 24, 202. The Medicare allowable for each date of service was $65 and the plan assessed a $40 copayment per date of service per the Plan contract. The Plan says that $40 x 6 days equals $240.
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 $40 copayment for each physical therapy visit. Once you became a private pay resident at the skilled nursing facility, individual copayments for services provided applied as opposed to being covered by the facility under a temporary stay. 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 $240 total copayment charged for physical therapy services provided from March 17, 2020, to March 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two unspecified removable prosthodontic procedures
(D5899), a complete upper denture (D5110) and a complete lower denture (D5120) provided on October 6,
2020.
You asked the Plan to pay for the unspecified procedure and dentures. You say that you expected these services
to be covered up to $2,000 because you have a $2,000 annual maximum for dental services. The Plan denied
your request. The Plan says an unspecified prosthodontic procedure is not covered by your dental benefit, and
the Plan has covered the dentures up to your responsibility for the 70% coinsurance. These claims were
processed 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). 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. Your contract with the Plan clearly says that you must pay 70% coinsurance for dentures.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested unspecified removable
prosthodontic procedures are not among those covered under this benefit. Therefore, we decided that the Plan
does not have to pay for two unspecified removable prosthodontic procedures (D5899) provided on October 6,
2020.
You have also been asked to pay $851.90 for each denture. The provider billed $2,112 for each denture. The
Plan's maximum allowed fee for one denture is $1,217, and you are required to pay 70% coinsurance of the
Plan's maximum allowed fee for dentures. ($1,217 x 70% coinsurance = $851.90 per denture). 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 pay any additional amount for the complete upper denture (D5110) and complete lower
denture (D5120) provided on October 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are medically necessary. The Plan denied your request. The Plan says the compression dressing are not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a Physical Medicine and Rehabilitation specialist on December 16, 2020.
You asked the Plan to waive the copayment for the specialist visit. You say that when you went to this doctor's office, you were told there was no charge when you checked out. The Plan denied your request. The Plan says you were charged this copayment 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 specialist visits.
You have been asked to pay a $50 copayment for the specialist visit. 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 visit you had with a Physical Medicine and Rehabilitation specialist on December 16, 2020.