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

We decided that the Plan does not have to waive the copayment for the emergency department visit (99281).

You asked the Plan to waive the copayment for the emergency department visit. You say that you should not have to pay the copayment for a short encounter. The Plan denied your request. The Plan says the copayment was 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 $90 copayment for each emergency care service provided in-network.

You have been asked to pay a $73.18 copayment for the emergency department visit. Emergency department visits fall within the Outpatient hospital 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 the emergency department visit (99281).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the adjustable bed.

You asked the Plan to reimburse you for the adjustable bed. You say that because of your back pain you got a physician order and bought the adjustable bed. The Plan denied your request. The Plan says you obtained durable medical equipment from a provider who does not participate with Medicare.

The Plan must follow Medicare rules. The rules say no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment.

We looked at the file and Medicare rules. The item at issue in this appeal was provided by a provider not certified by Medicare. Based on this information, we decided that Medicare rules for coverage of the adjustable bed have not been met. Therefore, we decided that the Plan does not have to reimburse you for the adjustable bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120) and the prophylaxis (D1110).

You asked the Plan to reimburse you for the dental services. You say that you have been seeing this dentist for the past 30 years. You say that your claim was paid. You also say that you feel you should be reimbursed in the amount of $119.31. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for services performed by a provider who has opted out of Medicare.

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, dental services performed by a provider who has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120) and the prophylaxis (D1110).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a mole removal (17000) provided October 30, 2019.

You asked the Plan to pay for a mole removal. You say that this service was medically necessary. The Plan denied your request. The Plan says this service was cosmetic and is therefore non-covered.

The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a mole removal have not been met. Specifically, the service at issue was cosmetic in nature and is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for a mole removal (17000) provided October 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.

You asked the Plan to pre-approve skilled nursing facility services. You say that these services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when four factors 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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical records do not show you 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 skilled nursing facility setting. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound scan (93971) provided on October 12, 2020.

You asked the Plan to waive the copayment for an ultrasound scan. You say that this should be covered with no cost-sharing. The Plan denied your request. The Plan says this 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). Your contract with the Plan clearly says that you must pay a $110 copayment for each Medicare-covered radiological diagnostic service. 

You have been asked to pay a $110 copayment for an ultrasound scan. 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 an ultrasound scan (93971) provided on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical cancer screening rendered on November 13, 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 you did not get a physical exam.

The Plan must follow Medicare rules. Medicare rules say that a cervical cancer screening is covered once every 24 months. 

We looked at the file and Medicare rules. The file shows that you received a cervical cancer screening on January 6, 2020 that the Plan covered. The screening on November 13, 2020 was performed less than 24 months from your previously covered exam and is therefore not covered. Therefore, we decided that the Plan does not have to pay for the cervical cancer screening rendered on November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) mechanical traction (97012) electrical stimulation unattended (97014) provided on November 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the chiropractic services. You say that you never received a notice that you would have to renew your services. Your doctor was unaware of it ending. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 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 chiropractic manipulative treatment (98940) mechanical traction (97012) electrical stimulation unattended (97014) provided on November 18, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on August 12, 2020.

You asked the Plan to pay for the dental service. You say that you are entitled to 2 free cleanings per year. You say that this bill is for a cleaning. You also say that you should not have to pay the deductible. The Plan denied your request. The Plan says this claim is for periodontal maintenance, not just a cleaning. The Plan also says that periodontal maintenance is subject to a $100 deductible.

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 periodontal maintenance is listed as a covered service, there is a $100 deductible for comprehensive dental services that must be met before the Plan will pay for covered services. The record shows that you received periodontal maintenance on this date of service. Although periodontal maintenance is listed as a covered service, the Evidence of Coverage says there is a 50% coinsurance of the covered plan allowance after the $100 annual deductible is met. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance provided on August 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facet joint injection (64490) provided on June 25, 2020.

You asked the Plan to waive the copayment for the facet joint injection. You say that you would like reconsideration because you did not have surgery and paid the $25 copayment requested at the time of service. The Plan denied your request. The Plan says this cost share amount was 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 $300 copayment for Outpatient Surgery. 

You have been asked to pay a $300 copayment for the facet joint injection. This injection falls within the Outpatient Surgery 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 facet joint injection (64490) provided on June 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skin graft (Grafix Prime).

You asked the Plan to pre-approve Grafix Prime. You say that Grafix Prime is medically necessary. The Plan denied your request. The Plan says the documentation provided is not sufficient to support the medical necessity and reasonableness for the request.

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 Grafix Prime. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that with documentation supporting failed reperfusion and ongoing limb ischemia, skin substitutes are not medically necessary presently. The review has determined that the requested skin graft (Grafix Prime) is not medically reasonable or 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 Grafix Prime have not been met. Therefore, we decided that the Plan does not have to pre-approve a skin graft (Grafix Prime).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the blepharoplasty (15823).

You asked the Plan to pay for the blepharoplasty. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code has an MUE of 1 and was billed twice.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 15823 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the blepharoplasty have not been met. Therefore, we decided that the Plan does not have to pay for the blepharoplasty (15823).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray.

You asked the Plan to pay for the intraoral periapical x-rays. You say that the Plan advised you that this provider was in-network. You also say that you do not understand why these services were not 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 first intraoral periapical x-ray and additional intraoral periapical x-ray.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost-share for the Denosumab (Prolia) injection (J0897) and injection service (96372).

You asked the Plan to reduce the cost-share for the drug injection. You say that your coverage booklet states that Prolia is a tier 4 drug and should only have a $100 copayment. The Plan denied your request. The Plan says Medicare Part B drugs require 20% coinsurance, and injection services provided by a specialist are subject to a $40 copayment.

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 Medicare Part B prescription drugs and a $40 copayment for physician services provided by a specialist.

You have been asked to pay 20% coinsurance for a Medicare Part B prescription drug. The Plan's allowed amount for the Denosumab (Prolia) is $1,156.80 and you have been asked to pay $231.36 ($1,156.80 x 20% = $231.36). The tiering chart you provided in your argument relates to your Part D prescription drug benefit. The injection you were provided was covered under your Part B benefit, therefore the Part D cost sharing rates do not apply. This means you have been asked to pay the correct amount for the Part B drug injection based on your contract with the Plan. If this is a service you will require in the future and you would prefer to pay the Part D cost-sharing amount, you may wish to contact the Plan to learn more about what drugs are eligible and how to get them covered under your Part D benefit.

You have also been asked to pay a $13.51 copayment for the administration of this drug. This drug was injected for you by a provider who specializes in endocrinology. Services provided by a specialist are subject to a $40 copayment. Because the Plan's allowed amount for this service was less than the copayment, you have only been asked to pay $13.51 instead of the full $40. 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 reduce the cost-share for the Denosumab (Prolia) injection (J0897) and injection service (96372).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper dentures.

You asked the Plan to pre-approve upper dentures. You say that upper dentures are medically necessary. The Plan denied your request. The Plan says this benefit is not currently available.

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, your denture benefit is only covered every five years. The records show your last denture benefit was paid in June of 2018. Therefore, we decided that the Plan does not have to pre-approve upper dentures.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on December 1, 2020.

You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 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 a domiciliary or rest home visit provided on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for the practitioner services.

You asked the Plan to waive the deductible and copayment for the practitioner services. You say that the Plan did not inform you that your provider was no longer in network. The Plan denied your request. The Plan says you signed an out-of-network waiver form before you received the services.

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 $225 deductible and a $50 copayment for physician/practitioner services. 

You have been asked to pay $114.58 for the practitioner services, which is an amount less than or equal to the remaining deductible, and copayment amounts. These services fall within the physician/practitioner 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 deductible and copayment for the practitioner services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided by a participating provider.

You asked the Plan to waive the copayment for wound care. You say that you did not have any outpatient surgery and you think this copayment is too high. 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 $175 copayment for outpatient surgery/in-network.

You have been asked to pay a $175 copayment for each wound care. The total amount you are being asked to pay is $1,400 ($175 x 8 visits = $1,400). Wound care is considered an outpatient surgery; therefore, the correct copayment has been applied. Wound care falls within the outpatient surgery/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 wound care provided by a participating provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided by an out of network (OON) provider from September 8, 2020, to September 16, 2020.

You asked the Plan to pay for psychotherapy services. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the services were provided out of network 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 psychotherapy services (90832) provided by an out of network (OON) provider from September 8, 2020, to September 16, 2020.