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

We decided that the Plan does not have to waive the copayment fora stress test provided on January 6, 2020.You asked the Plan to waive the copayment fora stress test. You say that you feel that the charges should be covered.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 $275 copayment for each stress test. You have been asked to pay the allowed amount of $243.85, which is less than the $275 copayment for a stress test. Astress test falls 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 copayment fora stress test provided on January 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on July 18, 2019.
You asked the Plan to waive the copayment for the endoscopy. You say that 100% of all patients with your condition require this procedure. You say that healthcare to prevent or detect illness at an early stage is covered. 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 $200 copayment for surgery services at an in-network ambulatory surgical center. You have been asked to pay a $200 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The endoscopy is considered a surgical procedure. 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 endoscopy provided on July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 23, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services provided on April 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 the laboratory services provided on November 5, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on August 8, 2019.
You asked the Plan to waive the coinsurance for the Part B injection. You say that you were told you would owe absolutely nothing. You say insurance and billing told you this would be expunged and off the record. 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). Your contract with the Plan clearly says that you must pay 10% coinsurance for Part B drugs that are administered by a provider. You have been asked to pay $156.11 which is 10% of the allowed amount for the Part B injection. The allowed amount is $1,561.09. ($1,561.09 x 10% = $156.11). The Part B injection falls within the "Medicare Part B prescription drugs" 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 Part B injection provided on August 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial maxillary denture.
You asked the Plan to pre-approve a partial maxillary denture. You say that your crown broke because the dentist put the crown in wrong. The Plan denied your request. The Plan says that they only cover this service once every five years.
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 one complete or partial denture every five years. We looked at the file and Medicare rules. The file indicates the plan covered a partial denture on September 7, 2016, which is less than five years ago. Based on this information, we decided that the Plan's rules for coverage of a partial maxillary denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial maxillary denture.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for urology services (CPT 52318 and CPT 52601) provided to the enrollee on August 20, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the service billed.
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, the CPT Code Manual definition of the denied codes is: CPT 52318: Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (over 2.5 cm) CPT 52601: Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete We asked our coding 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the medical records provided do not provided enough information to verify that a Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (over 2.5 cm) and a Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included) were performed on August 20, 2019. The operative note has multiple dates documented but none conclusively state the date of service was August 20, 2019, therefore these services cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for urology services (CPT 52318 and CPT 52601) provided to the enrollee on August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 1 additional periapical x-ray (D0220) and the core build up (D2950) provided from November 4, 2019 to November 18, 2019.
You asked the Plan to pay for the dental services. You say that a plan representative advised that one cap or crown would be covered 100% per year. You say that you received multiple bills for the services. You say that you are on Social Security and do not have money to pay these bills. The Plan denied your request. The Plan says periapical x-rays and core build up are not listed as covered services.
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, core build up and the additional periapical x-ray are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 1 additional periapical x-ray (D0220) and the core build up (D2950) provided from November 4, 2019 to November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on February 18, 2019.
You asked the Plan to pay for the orthoses. You say that the claim has not been paid and it should be. The Plan denied your request. The Plan says the order form for the durable medical equipment has a date of service that does not match the date of service in the appeal.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. The date of service occurred before the order form was signed and the office visit. The services date was February 18, 2019 and the order form and office visit was signed on March 27, 2019. The prescription must be submitted to the supplier prior to the delivery. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on February 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the ambulance services provided on October 7, 2019.
You asked the Plan to reimburse you for ambulance services for the enrollee's transfer to the nursing facility near your home. You say that you were displaced by a hurricane and needed to get the enrollee back near home. The Plan denied your request. The Plan says you were denied authorization on October 4, 2019.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. The enrollee was not transferred to the nearest facility. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does not have to reimburse you for the ambulance services provided on October 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on September 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a drug test. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.
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 a drug test provided on September 16, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automated blood pressure cuff.
You asked the Plan to pre-approve the cuff. You say that this is medically necessary, as you are unable to physically use a manual blood pressure cuff. The Plan denied your request. The Plan says this is not a covered benefit unless you are on home dialysis.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automated blood pressure cuff.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on February 18, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that the technician made a mistake and you had to have the CT scan done. 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 $275 copayment for each advanced imaging service. You have been asked to pay a $275 copayment for a CT scan. A CT scan falls 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 copayment for a CT scan provided on February 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rhopressa solution for the enrollee.
You asked the Plan to pre-approve Rhopressa. You say that the medication has been effective for the enrollee. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rhopressa solution for the enrollee.
Benefits for Rhopressa may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental evaluation (D0120), prophylaxis (D1110) and intraoral (D0220) provided on October 29, 2019.
You asked the Plan to pay for the dental services. You say that you would like reconsideration because the contract does not specify that the member must use network providers. The Plan denied your request. The Plan says the member received dental services from an out-of-network provider and there was no authorization on file.
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 the dental services when select services are rendered by a participating provider. We looked at your request, the file, and the rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, these services do not meet criteria for out-of-network coverage. Therefore, we decided that the Plan does not have to pay for the dental evaluation (D0120), prophylaxis (D1110) and intraoral (D0220) provided on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick injection 140mg/ml for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick injection 140mg/ml for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you cannot afford to pay for your mother's stay in a SNF. You say that no one cares and no one is listening. You say that you are worried about the quarantine and having your mother transferred to the home. The Plan denied your request. The Plan says the enrollee's medical status is stable and she does not require daily skilled care. The Plan says that the care needed can be safely provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, was alert with confusion, received a course of IV fluids, and was monitored for falls. The enrollee received physical therapy and occupational therapy in the SNF. The enrollee was at a moderate to maximal assist level with med mobility and transfers. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs or skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that you are asking for these services because the enrollee has a recent Covid diagnosis and cannot state her symptoms and needs intense monitoring. The Plan denied your request. The Plan says that temperature taking and monitoring vital signs is not a skilled service.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. You do not have complex wound care or other new SNF level skilled nursing need. Your colostomy is not brand new. Your Foley does not need a SNF admission. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF. As a practical matter you do not require the necessary services on an inpatient basis, in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.