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

We decided that the Plan does not have to waive the coinsurance for outpatient surgery (63047) provided August 18, 2020 to August 19, 2020.
You asked the Plan to waive the coinsurance for the outpatient surgery. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost-sharing was 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 20% coinsurance for Outpatient Hospital Services. You have been asked to pay a 20% coinsurance for the outpatient surgery. The outpatient surgery falls 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 coinsurance for outpatient surgery (63047) provided August 18, 2020 to August 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee on June 5, 2020.You asked the Plan to pay forhome health services. You say that type of billed 0324 is valid.The Plan denied your request. The Plan says this was not billed with the correct type of bill.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this was billed with a type of bill code of 0324, which is not a valid type of bill for home health services.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee on June 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the external defibrillator provided on June 29, 2020.
You asked the Plan to waive the coinsurance for the external defibrillator. You say that you were not informed of the cost. You say that it is difficult to make an informed decision without knowing the 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% of the plan-allowed amount for Medicare-covered durable medical equipment from an in-network provider. You have been asked to pay $614.38, which is 20% of the allowed amount for the external defibrillator. The allowed amount is $3,071.88 (20% x $3,071.88 = $614.38). The external defibrillator falls within the "Durable medical equipment (DME) and related 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 coinsurance for the external defibrillator provided on June 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on April 6, 2020,and the mastectomy provided on May 19, 2020,and June 9, 2020.You asked the Plan to waive the copayment forthe office visit and mastectomy. You say that the surgery was medically necessary to prevent the spread of cancer. You say that you cannot afford to pay $740.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 $40 copayment for each specialist visit for Medicare-covered benefits and a $350 copayment for each Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. 

You have been asked to pay a total of $740 for the office visit and mastectomy. Date of ServiceServiceStandard CopaymentMember LiabilityApril 6, 2020Office Visit $40$40May 19, 2020Mastectomy$350$350June 9, 2020Mastectomy$350$350TOTAL:$740The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The mastectomy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe office visit provided on April 6, 2020, and the mastectomy provided on May 19, 2020, and June 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiography for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of concerning symptoms that might necessitate another echo.
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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has moderate grade aortic valve regurgitation on a recent echocardiogram 08/13/20 as well as a stable ascending aortic aneurysm being followed by serial CT scans. In this circumstance of a clinically stable patient with non-severe aortic regurgitation the records do not support the medical necessity for a repeat echocardiogram less than one year after the prior exam. 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 a transthoracic echocardiography for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the pulp vitality tests (D0460) provided on August 24, 2020.
You asked the Plan to reimburse you for the dental services. You say that you had a crown that fractured and fell off. You say that the x-rays were only on the area that is of particular in question. You say that you will continue to see this dentist. You say that you have a second crown that needs to be replaced. You also say that these service should be covered due to an emergency situation. The Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. The Plan says that the periapical x-ray is not listed as a covered service. The Plan also says that the pulp vitality test is not listed as a covered service.
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 reimburse you for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the pulp vitality tests (D0460) provided on August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140) and porcelain/ceramic crown (D2740) provided June 9, 2020, to June 16, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe limited oral evaluation and porcelain/ceramic crown. You say that you would like these claims reprocessed and approved for payment.The Plan denied your request. The Plan says unless prior authorization is obtained, services are only covered when provided by the contracted dentist.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 limited oral evaluation and porcelain/ceramic crown when the services are performed by a contracted provider with the Plan. 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 Planto pay for these dental services.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140) and porcelain/ceramic crown (D2740) provided June 9, 2020, to June 16, 2020, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe outpatient surgery provided on April 4, 2018.You asked the Plan to waive the deductible forthe outpatient surgery. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received outpatient surgery on the date of service at issue in this appeal. The Plan says that the correct amount has applied towards your deductible per your contract with the Plan.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $1000 deductible that must be met before the Plan will pay their share for Outpatient hospital services. The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1000 deductible that must be met before the Plan will pay their share for Outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the time the outpatient surgery was received on April 4, 2018.Therefore, we decided that the Plan does not have to waive the deductible forthe outpatient surgery provided on April 4, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic crown services (D2740) provided on August 5, 2020.
You asked the Plan to pay for the porcelain/ceramic crown services. You say that the teeth started to darken and you needed this procedure done. The Plan denied your request. The Plan says these services are being performed for aesthetics and 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. The Plan covers the porcelain/ceramic crown services when the services are medically necessary and reasonable. We looked at the file and Medicare rules. The file indicates that you are having these services performed for aesthetic reasons to match the other teeth in your mouth. Based on this information, we decided that the Plan's rules for coverage of the porcelain/ceramic crown services have not been met. Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic crown services (D2740) provided on August 5, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided from June 8, 2020, to June 30, 2020.You asked the Plan to pay for the skilled nursing facility services. The Plan denied your request. The Plan says Original Medicare would be responsible for paymentof all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit,through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge orrevocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated tothe terminal illness until the first dayof the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on June 2, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for skilled nursing facility services provided from June 8, 2020, to June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 29, 2020, by an OON provider.You asked the Plan to pay fora domiciliary or rest home visit. You say that these medically necessary services were provided to the enrollee in good faith.The Plan denied your request. The Plan says these services were provided with no 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, outof 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 items/servicesat 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 forthe medical services provided on May 29, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing foran automatic external defibrillator (K0606) provided on July 29, 2020.You asked the Plan to waive the cost-sharing foran automatic external defibrillator. You say that you were not informed of the cost of this item.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 20% coinsurance for durable medical equipment. You have been asked to pay a $614.37 coinsurance ($3,071.88 allowed amount x 20% coinsurance = $614.37) for an automatic external defibrillator. An automatic external defibrillator falls within the durable medical equipment 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 thecost-sharing foran automatic external defibrillator (K0606) provided on July 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the plan has no contractual obligation to cover services that are not reasonable and 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee requires skilled nursing or therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse or qualified therapist is not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. The enrollee does not require the services on an inpatient basis, in a skilled nursing facility setting. Services in the long-term care facility appear appropriate in this case. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided on June 8, 2020.You asked the Plan to pay forthe dental services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says you did not activate the Optional Supplemental Dental Rider when you received the dental services at issue in this appeal.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth.These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe dental services provided on June 8, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs provided on January 10, 2020.
You asked the Plan to waive the coinsurance for the Part B drugs. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received Part B drugs on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.
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 20% coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received Part B prescription drugs on January 10, 2020. You have been asked to pay a 20% coinsurance for the Part B drugs, totaling $305.99. The Part B drugs fall 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 drugs provided on January 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTheraSkin (Q4121, 15271).You asked the Plan to pre-approveTheraSkin. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has notbeen established. Therefore, coverage criteria has not been met.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve TheraSkin. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found separately, the wound is reported to be granulating on its own with standard wound care. There is also no reason the enrollee could not undergo a skin graft if necessary however, placement of the skin graft on healing AV fistulawound is not considered a standard treatment.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TheraSkin have not been met.Therefore, we decided that the Plandoes not have to pre-approveTheraSkin (Q4121, 15271)
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network (OON) provider.

You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the provider in question is not in network.

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 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 medical services provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe core build up (D2950), the pin retention (D2951) provided on August 19, 2020.You asked the Plan to reimburse you forthe dental services. You say that your card says you have dental coverage. You say that up to $2,000 is covered for dental services. You also say that the refusal to cover the claim is fraudulent and of bad faith.The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan also says that pin retention is not listed as a covered service.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 reimburse you forthe core build up (D2950), the pin retention (D2951) provided on August 19, 2020.
Your complaint about the refusal of payment on the part of the Plan as fraudulent and of bad faith 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.