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

We decided that the Plan does not have to pay for the laboratory services rendered on April 30, 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 claim was 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 April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Paclitaxel, Carboplatin, Palonosetron, Dexamethasone, and Fosaprepitant.
You asked the Plan to pre-approve Paclitaxel, Carboplatin, Palonosetron, Dexamethasone, and Fosaprepitant. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee is enrolled in a clinical trial.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve Paclitaxel, Carboplatin, Palonosetron, Dexamethasone, and Fosaprepitant as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Paclitaxel, Carboplatin, Palonosetron, Dexamethasone, and Fosaprepitant.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on October 20, 2020 and October 22, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that the cost of the hospitalization should be covered. You say that the hospitalization was necessary to your recovery. 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 $10 copayment for in-network physical therapy. You have been asked to pay a $10 copayment for each physical therapy visit. The total amount you owe is $20 ($10/visit x 2 visits = $20). Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided on October 20, 2020 and October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on August 24, 2020.
You asked the Plan to waive the copayment for specialist services. You say that you disagree with the charges because the doctor did not perform the services they listed in your chart. 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 $50 copayment for specialist visits. You have been asked to pay a $50 copayment for specialist services. Specialist services fall 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 specialist services provided on August 24, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to reimburse you additionally for the outpatient mental health services provided from September 2, 2020, to October 23, 2020.
You asked the Plan to reimburse you additionally for the outpatient mental health services provided out-of-network. You say that you were not reimbursed the correct amount. The Plan denied your request. The Plan says you were reimbursed the Medicare allowable amount minus your copayments.
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 $35 copayment for Outpatient Mental Health Care and your costs may be higher if you use an out-of-network provider. You have been asked to pay a $35 copayment for the outpatient mental health services provided out-of-network. The outpatient mental health services provided out-of-network fall within the Outpatient Mental Health 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. The Plan has reimbursed you the Medicare allowable rate for out-of-network services. Therefore, we decided that the Plan does not have to reimburse you additionally for the outpatient mental health services provided from September 2, 2020, to October 23, 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.
You asked the Plan to pre-approve the LTACH services. You say that the level of care the enrollee requires can only be achieved at an LTACH. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting.
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 physician reviewer found that the enrollee was admitted to the acute hospital for septic shock and acute hypoxemic respiratory failure. Her hospital course was complicated by a myocardial infarction, and anemia. She was intubated. There is no documentation that she is capable of being weaned at this time. She is receiving appropriate care at the present acute care hospital. She does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services are not medically 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110), the complete lower denture (D5120), and the panoramic x-ray (D0330) provided from October 16, 2020, to November 2, 2020.
You asked the Plan to pay for the dental services. You say that you contacted the plan 2 times to ensure that the dentist was okay and how much would be covered for the dentures. You say that you were advised both times that dentures were covered at 100%. You say that when you went to pick up your teeth, you were advised that you needed to pay $1,648 for them. You also say that you cannot afford to pay this. The Plan denied your request. The Plan says there is an annual maximum benefit of $2,000. The Plan also says that the annual maximum benefit has been exhausted. The Plan says that at the time when you contacted the Plan on August 26, 2020, the claim for the extractions had not been processed. The Plan also says that no inaccurate information was provided.
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 the services are listed as covered, the annual maximum benefit of $2,000 for dental services has been exhausted. The record shows that the Plan paid $119 for dental services that you received on July 17, 2020, and $1,881 for dental services that you received on August 20, 2020. Additionally, the record shows that the claim for date of service August 20, 2020, had not processed at the time of your call to the plan on August 26, 2020, thus inaccurate information was not provided during the phone call. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110), the complete lower denture (D5120), and the panoramic x-ray (D0330) provided from October 16, 2020, to November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two localized deliveries of antimicrobial agents, two gingival irrigations, and drugs or medicaments dispensed in the office for home use provided on February 27, 2020.
You asked the Plan to pay for the localized deliveries of antimicrobial agents, gingival irrigations, and drugs or medicaments. You say that you believe these services should be covered. The Plan denied your request. The Plan says these 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. 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 two localized deliveries of antimicrobial agents, two gingival irrigations, and drugs or medicaments dispensed in the office for home use provided on February 27, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the infection control supplies coded S8301 and the Iv tubing extension set coded S1015 provided on September 15, 2020.
You asked the Plan to pay for the infection control supplies and the Iv tubing extension set. 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 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. We find that CPT codes S8301 and S1015 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the infection control supplies and the Iv tubing extension set have not been met. Therefore, we decided that the Plan does not have to pay for the infection control supplies coded S8301 and the Iv tubing extension set coded S1015 provided on September 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records do not indicate that the criteria has been met.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 bed. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does not clearly reveal that your condition has failed positioning of the bed in ways not feasible in an ordinary bed, or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically 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 the bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2335) for tooth # 26 provided on November 25, 2020.
You asked the Plan to pay for the dental service. You say that you had to wait in the waiting room for about an hour for a procedure that took 25 minutes. You say that you had to reschedule the appointment multiple times. You also say that you had gotten approval for this service prior to your appointment. The Plan denied your request. The Plan says 1 filling per year is covered. The Plan says that the frequency limit for this service 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 fillings are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the filling for tooth # 25 that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the filling (D2335) for tooth # 26 provided on November 25, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided by a participating provider on January 2, 2020, to January 17, 2020.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that the correct copayments have been applied. 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 $35 copayment for outpatient rehabilitation services/in-network. You have been asked to pay a $35 copayment for each outpatient rehabilitation service. The total amount you are being asked to pay is $175 ($35 x 5 sessions = $175). The correct copayments have been applied to the services that were provided. Outpatient rehabilitation services fall within the outpatient rehabilitation services/in-network 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 outpatient rehabilitation services provided by a participating provider on January 2, 2020, to January 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission provided from October 23, 2020, to November 21, 2020.
You asked the Plan to pay for the SNF admission. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee received therapy approximately 2 to 3 times per week. The Plan says that this does not satisfy the requirement of daily therapy needs in order for Medicare to cover admission to a SNF.
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 pay for the SNF admission. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. Although the enrollee received physical and occupational therapies, they did not require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission provided from October 23, 2020, to November 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oscillation system provided on December 4, 2020.
You asked the Plan to waive the coinsurance for the oscillation system. You say that the charge is incorrect because you had met your individual out-of-pocket cost. 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 durable medical equipment from an in-network provider. You have been asked to pay $157.47, which is 20% of the allowed amount for the oscillation system. The allowed amount is $787.37 (20% x $787.37 = $157.47). The oscillation system falls within the "Durable medical equipment (DME) and related supplies" benefit category. The records show your out-of-pocket maximum was not met due to claims being reprocessed. 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 oscillation system provided on December 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the panoramic x-ray (D0330) provided on December 7, 2020.
You asked the Plan to pay for the dental services. You say that you did not go to this provider for your teeth. You say that you were experiencing facial pain. You say that you do not know why the claim was sent to Dental. You also say that the services should be covered under the medical due to being told it would be. The Plan denied your request. The Plan says the services you received are dental in nature. The Plan says 1 limited oral evaluation is covered per plan year. The Plan says that 1 panoramic x-ray is covered every 3 plan years. The Plan says that the frequency limits have 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 the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on August 26, 2020. The record shows that the Plan paid for a panoramic x-ray that you received on October 8, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the panoramic x-ray (D0330) provided on December 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for basic radiology services provided on September 30, 2020, and October 23, 2020.
You asked the Plan to waive the copayments for basic radiology services. You say that you disagree with the charges because you feel that they should be considered preventative. 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 $105 copayment for basic radiology services provided in an outpatient hospital facility. You received basic radiology services on September 30, 2020. Therefore, you are responsible to pay the allowed amount of $78.60, which is less than the $105 copayment. You received basic radiology services on October 23. 2020. Therefore, you are responsible to pay the $105 copayment. The total amount you owe is: $183.60. You have been asked to pay the total copayment amount of $183.60 for basic radiology services. Basic radiology services fall within the outpatient diagnostic tests and therapeutic services and 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 copayments for basic radiology services provided on September 30, 2020, and October 23, 2020.