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

We decided that the Plan does not have to waive the copayment for lab services provided on December 21, 2020.

You asked the Plan to waive the copayment for lab services. You say that you disagree with the charges. 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 $15 copayment for lab services provided in an outpatient hospital facility. 

You received lab services on December 21, 2020, at an outpatient hospital facility. Therefore, you are responsible to pay the $15 copayment. 

You have been asked to pay a $15 copayment for lab services. Lab 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 copayment for lab services provided on December 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from January
16, 2020, through January 21, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were prematurely
discharged you were charged in error for two separate stays. You say that you were unaware you would be
charged separately and should have only been charged for one continuous stay. 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 $450
copayment each day for days 1 to 4 for in-network, Medicare-covered hospital care. $0 copayment for
additional Medicare-covered days.
You have been asked to pay a $1,800 copayment for the inpatient stay. ($450/day x 4 days = $1,800). The
inpatient stay falls within the "Inpatient Hospital Care" benefit category. The records show this was a separate
stay. This means that you have been asked to pay the correct amount based on your contract with the Plan. This
cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided
that the Plan does not have to waive the copayment for the inpatient stay provided from January 16, 2020,
through January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on January 14, 2021.
You asked the Plan to pay for the dental service. You say that your dentist retired. You say that you had to be
seen as a new patient with this dentist. You say that a new panoramic x-ray was necessary since your previous
records could not be accessed. You also say that you should not be responsible for this charge. The Plan denied
your request. The Plan says 1 panoramic x-ray is covered every 3 plan 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 panoramic x-ray is listed as
covered, the frequency limit has been exceeded. The record shows that the plan paid for a panoramic x-ray that
you received on December 14, 2019. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair lift provided on January 6, 2021.
You asked the Plan to pay for a stair glide. You say that you would like reconsideration because there is no
way to get in and out of the home without the assistance of a stair lift. The Plan denied your request. The Plan
says this provider is not a certified Medicare provider and Medicare guidelines specifically state, doctors and
suppliers have to meet strict standards to enroll and stay enrolled in Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature. The rules also say that no provider or supplier shall receive payment for
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare
program.
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Additionally, this provider is not certified with Medicare, therefore; payment may not be made. Therefore, we
decided that the Plan does not have to pay for a stair lift provided on January 6, 2021.
Your complaint about being given incorrect information by the Plan 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services (97530) provided on February 18, 2020.
You asked the Plan to pay for occupational therapy services. You say that this should be covered. The Plan denied your request. The Plan says this was not billed correctly.
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 code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, because this service was provided in a home health setting, there is a more appropriate code for billing this service. Based on this
information, we decided that Medicare rules for coverage of occupational therapy services have not been met. Therefore, we decided that the Plan does not have to pay for occupational therapy services (97530) provided on February 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on August 11,
2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that the services were provided with no adequate
time to obtain authorization. The Plan denied your request. The Plan says authorization for out-of-network
services was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the 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 outpatient mental health services provided on August 11, 2020 by an out of
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the eye exam provided on February 5, 2021.

You asked the Plan to waive the copay for the services provided. You say that routine eye exams are covered with no copay. The Plan denied your request. The Plan says the claim applied the correct benefits.

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 copay for each specialist office visit for vision services. 

The claim provided shows that you received an eye exam for the treatment of a cataract condition. This is a Medicare-covered exam for the treatment of diseases of the eye. You have been asked to pay a $30 copay for the services provided. The services fall within the vision 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 copay for the eye exam provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 16, 2020 by an out of network provider.

You asked the Plan to pay for Subsequent nursing facility care (99307). You say that the doctor depends on the hospital staff to verify eligibility and obtain authorization. The Plan denied your request. The Plan says you did not request 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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on June 16, 2020 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that
were issued on December 17, 2020.
You asked the Plan to pay for the compression stockings. You say that you would like this claim reprocessed
and approved for payment. The Plan denied your request. The Plan says this item is non-covered, and the
provider is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression
stockings identified with code A6533 that were issued on December 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of inflatable urethral/bladder neck sphincter,
including placement of pump to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve insertion of inflatable urethral/bladder neck sphincter, including placement
of pump provided by an OON provider. You say that you would like the Plan to reconsider their denial. The
Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network
care. The Plan says there are equally qualified in-network specialist's available to you that can provide
the surgical procedure you are requesting.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
insertion of inflatable urethral/bladder neck sphincter, including placement of pump to be provided by an out of
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the out-of-network office visit provided on October 9, 2020.
You asked the Plan to waive the cost share for the office visit. You say that it is not fair to kick the provider off the network due to his employee's negligence. The Plan denied your request. The Plan says the cost share applied per out of network benefits.
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 50% of the Medicare-allowed amount for out-of-network physician services.
You have been asked to pay 50% of the Medicare-allowed amount for the out-of-network office visit provided. The office visit falls within the physician 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 cost share for the out-of-network office visit provided on October 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for physical therapy visits provided from December 1, 2020, through December 31, 2020.

You asked the Plan to waive the co-payment for the physical therapy visits. The Plan denied your request. The Plan says the claim applied the correct benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $25 co-payment for outpatient rehabilitation services.

You have been asked to pay $25 co-payment for the physical therapy visits. The physical therapy visits 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 co-payment for physical therapy visits provided from December 1, 2020, through December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete upper denture (D5110), and a complete lower denture (D5120) provided on January 11, 2021.

You asked the Plan to pay for a complete upper denture, and a complete lower denture. You say that you were told by the provider that the services would be covered. The Plan denied your request. The Plan says the services at issue are not a covered benefit.

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 a complete upper denture (D5110), and a complete lower denture (D5120) provided on January 11, 2021.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve home health skilled nursing services (G0299).
You asked the Plan to pre-approve these services. You say that home health skilled nursing services are medically necessary. The Plan denied your request. The Plan says home health services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that home health skilled nursing services are medically necessary. Our physician reviewer found that you have documented skilled nursing needs, requiring regular wound care for a wound that is in a hard-to-see and hard-to-reach location. While the health plan argues that you are not homebound, the health plan has provided proof of only one outpatient visit, during which you were noted to have had several recent hospitalizations and to be using a walker. How you were able to get to and from the outpatient appointment is unclear. The visiting nurse notes that leaving the home requires a taxing effort. The health plan has failed to show regular outpatient visits and that these visits did/do not require a taxing effort to attend. As such, home health skilled nursing services for ongoing wound care is medically necessary and reasonable. 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 home health services have been met. Therefore, we decided that the Plan has to pre-approve home health skilled nursing services (G0299).
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on August 24, 2020, by an out of network provider.
You asked the Plan to pay for psychotherapy services. You say that the provider rendered treatment to the enrollee in good faith. The Plan denied your request. The Plan says rules for out of network care have not been met.
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 psychotherapy services (90837) provided on August 24, 2020, by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental crowns described by dental codes D6752 and D6242.
You asked the Plan to pre-approve dental codes D6752 and D6242. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental codes D6752 and D6242 are not covered under your supplemental dental benefit.
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 codes D6752 and D6242 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental crowns described by dental codes D6752 and D6242.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 21, 2021 provided on January 21, 2021 by an out of network (OON) provider.

You asked the Plan to pay for lab tests. You say that the enrollee was switching from Original Medicare and was expecting to receive the same level of coverage. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.

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 laboratory testing provided on January 21, 2021 provided on January 21, 2021 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you are only covered for up to 48 one-way trips per calendar year and additional trips will not be provided.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 one-way transportation trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.