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

We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided by a participating provider on March 15, 2021.
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that this should have been a screening. You say that you were not charged for this last year. 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 $60 copayment for outpatient diagnostic tests/ultrasound. 
You have been asked to pay a $60 copayment for a diagnostic ultrasound. When additional tests are done that go beyond a preventative screening, additional copayments are applied; therefore, the correct copayment has been applied. A diagnostic ultrasound falls within the outpatient diagnostic tests/ultrasound 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 ultrasound provided by a participating provider on March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) provided on February 12, 2020.

You asked the Plan to pay for the bone replacement graft. You say that you were not told in advance that the treating provider was not in-network. The Plan denied your request. The Plan says this service is not covered under your plan.

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 bone replacement graft for ridge preservation (D7953) provided on February 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary for the care and recovery for the member. The Plan denied your request. The Plan says that records show you have not completed your course in the hospital.

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. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, 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. The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 

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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient substance abuse admission provided from December 2, 2019, through December 31, 2019.
You asked the Plan to pay for the inpatient substance abuse admission. You say that the facility shows that they take your insurance so you do not know why the admission would not be covered. The Plan denied your request. The Plan says the facility is not certified with Medicare and is out of network with the plan.
The Plan must follow Medicare rules. Medicare rules say Medicare rules say that a Substance Abuse Facility is not eligible to participate in the Medicare program. 
We looked at the file and Medicare rules. The provider at issue in this case is a Substance Abuse Facility. Medicare says that a Substance Abuse Facility is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for inpatient substance abuse admission provided from December 2, 2019, through December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 14, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 18, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you saw a physician's assistant and not the specialist. 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 $10 copayment for specialist visits. 

The medical records show that you received specialist services on February 18, 2021. Therefore, you are responsible to pay the $10 copayment. 

You have been asked to pay a $10 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the prophylaxis (D1110) and the periodic oral evaluation (D0120) received January 19, 2021 from the out-of-network provider.
You asked the Plan to pay an additional amount for the prophylaxis and periodic oral evaluation. You say that your contract states benefits for in and out of network are the same. The Plan denied your request. The Plan says you were charged the difference between what the Plan pays and what was charged by the out-of-network provider.
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. The Plan contract clearly states that if you choose to see an out-of-network dentist you might be billed for charges above what the Plan pays, even for services listed as $0 copayment. 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 an additional amount for the prophylaxis (D1110) and the periodic oral evaluation (D0120) received January 19, 2021 from the out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from February 24, 2021, to February 25, 2021.
You asked the Plan to pay for inpatient care. You say that you cannot afford these charges. The Plan denied your request. The Plan says this claim processed correctly.
The Plan must follow Medicare rules. Medicare rules say that if a hospital wishes to bill non-covered procedure(s) and related non-covered charges for whatever reason (e.g., a Medicare denial), the hospital may submit such services/charges on a type of bill (TOB) 110 (no-pay claim). 
We looked at the file and Medicare rules. The facility submitted the claim at issue with a TOB of 110, indicating that the services were non-covered. Based on this information, we decided that Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care provided from February 24, 2021, to February 25, 2021.
Your complaint about being liable for these charges is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to hold the enrollee harmless for the ambulance service, advanced life support, emergency transport, level 1(A0427) provided October 14, 2020.

You asked the Plan to hold the enrollee harmless for the ambulance service. You say that the service was medically necessary. The Plan denied your request. The Plan says that you were not transported by the ambulance and therefore the service is not covered under your plan.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

The enrollee was referred for the ambulance service by a contract provider. The file does not show that the plan provided notice that the ambulance service would not be covered. Under Medicare rules, this means the ambulance service is considered approved by the plan. Therefore, we decided that the Plan has to hold the enrollee harmless for the ambulance service, advanced life support, emergency transport, level 1(A0427) provided October 14, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.

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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the neurostimulator treatment provided on March 31, 2021.

You asked the Plan to waive the copayment for the neurostimulator treatment. You say that you submitted an appeal to have the copayments for your treatments reduced and it was approved. You say that these are recurring monthly treatments and you are being charged the full copayment again. The Plan denied your request. The Plan says the previous copayment was removed in error and this 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 $30 copayment for in-network physician specialist services.

You have been asked to pay a $30 copayment for the neurostimulator treatment. The neurostimulator treatment falls within the "Physician/Practitioner services, including doctor's office visits" 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 neurostimulator treatment provided on March 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) heart, without contrast material, with quantitative evaluation of coronary calcium (75571).

You asked the Plan to pre-approve the CT scan. You say that you had seen the cardiologist because you had a TIA in April. During the scan they said they could not see where the blood clots were. They ordered the CT scan to see if there is something on the lower half of your heart. The Plan denied your request. The Plan says there is not enough evidence to show the medical need to evaluate measurements of calcium in the heart.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found coronary calcium scanning can be indicated in patients at intermediate risk for a cardiovascular event to further refine risk if a statin is being considered. However, in this instance, the enrollee has already had a atherosclerotic vascular event (TIA/stroke) in the setting of hyperlipidemia and a statin medication would still be indicated even if there was a low calcium score noted on a coronary CT calcium scan. The results of the CT calcium scan would not change the recommended management and therefore would not be considered medically necessary in this clinical situation.

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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) heart, without contrast material, with quantitative evaluation of coronary calcium (75571).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower denture (D5120) provided on March 31, 2021.

You asked the Plan to pay for the dental items. You say that the dentures should be covered. The Plan denied your request. The Plan says dentures are covered once every 5 years. 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 dentures are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for dentures that you received on March 4, 2019. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower denture (D5120) provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for debridement and strapping provided from December 4, 2020, to May 14, 2021.

You asked the Plan to waive the copayments for debridement and strapping. You say that you disagree with the surgical charges because you did not receive surgery services. 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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers provided in 2020 and a $290 copayment when provided in 2021.

You received debridement and strapping at an outpatient hospital facility from December 4, 2020, to May 14, 2021, for a total of 23 services. Debridement and strapping are considered outpatient surgical procedures. Therefore, you are responsible to pay the total allowed amount of $3,611.48, which is less than the total copayment amount.

You have been asked to pay the total amount of $3,611.48 for debridement and strapping. Debridement and strapping fall 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 copayments for debridement and strapping provided from December 4, 2020, to May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit and a diagnostic test provided by a participating provider on February 22, 2021.
You asked the Plan to waive the copayment for a specialist office visit and a diagnostic test. You say that you have never had to pay for these visits before. You say that you think you are being incorrectly charged. The Plan denied your request. The Plan says the correct copayments have 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 $40 copayment for physician/practitioner services/specialist physician services and a $50 copayment for outpatient diagnostic tests/outpatient diagnostic tests.
You have been asked to pay a $40 copayment for a specialist office visit. You have also been asked to pay $43.76 which is less than your copayment amount of $50 for a diagnostic test. The total amount you are being asked to pay is $83.76 ($40 + $43.76 = $83.76). a specialist office visit and a diagnostic test falls within the physician/practitioner services/specialist physician services and outpatient diagnostic tests/outpatient diagnostic tests 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 specialist office visit and a diagnostic test provided by a participating provider on February 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 24, 2020.

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 claims were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on March 8, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you do not feel that you should be penalized because dentists keep opting out of the Plan's network. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation 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, comprehensive oral evaluation is limited to one procedure every three years. The record shows that you received a comprehensive oral evaluation on April 23, 2019 and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on March 8, 2021.