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

We decided that the Plan does not have to waive the copayment for a laparoscopy provided on November 20, 2020.
You asked the Plan to waive the copayment for a laparoscopy. You say that you disagree with how high the charges are. 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 15% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities. You received a laparoscopy on November 20, 2020. The total allowed amount is $8,055.22 and 15% of that is $1,208.28. You have been asked to pay the total coinsurance amount of $1,208.28 for a laparoscopy. A laparoscopy 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 for a laparoscopy provided on November 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider on November 7, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you could not drive to the hospital and you live alone. You say that you called the ambulance to try to help. You say that you did not get transported by the ambulance. 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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided by a participating provider on November 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an oral evaluation (D0120), problem focused evaluation (D0140), bitewing x-rays (D0272) and cleaning (D1110) provided on January 28, 2020 and July 30, 2020.
You asked the Plan to pay for the dental services. You say that you were told by the Provider that you could be reimbursed for these services. You have had other claims reimbursed, so you do not understand why the Plan will not reimburse these services. The Plan denied your request. The Plan says in order to use your supplemental dental benefits, they must be provided by a licensed dental provider who participates in Medicare. The provider in question does not accept Medicare payments or participate in Original Medicare. Therefore, you cannot be reimbursed for these services as the care is 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, care provided by a non-participating provider is covered under this benefit. Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0120), problem focused evaluation (D0140), bitewing x-rays (D0272) and cleaning (D1110) provided on January 28, 2020 and July 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for the ForeseeHome ARMD monitoring
program with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no reason to cover this at the in-network benefit level.
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
a referral for the ForeseeHome ARMD monitoring program with an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department visit (99285) and electrocardiogram, routine ECG with at least 12 leads (93010) provided September 26, 2020.
You asked the Plan to pay for the emergency visit. You say that the claim was filed in the 60-day deadline and you feel that this service should have been covered by the Plan. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for emergency department visit (99285) and electrocardiogram, routine ECG with at least 12 leads (93010) provided September 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for neuropathy treatments provided from August 11, 2020, to November 18, 2020.
You asked the Plan to reimburse you for neuropathy treatments. You say that the neuropathy treatments are really helping, and you would like to get them paid for. The Plan denied your request. The Plan says the provider has stated that insurance does not covered these treatments.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The record shows there are no Current Procedural Terminology (CPT) codes for the therapy and the therapy has not been approved for payment by any insurance. Based on this information, we decided that Medicare rules for coverage of neuropathy treatments have not been met. Therefore, we decided that the Plan does not have to reimburse you for neuropathy treatments provided from August 11, 2020, to November 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for the tooth extraction (D7210) provided on December 10, 2020.
You asked the Plan to fully pay for the extraction. You say that you called the Plan prior to services and verified that you still had $842 left before you hit your maximum allowance. The Plan denied your request. The Plan says you received multiple services on the date in question, for which the provider billed $1,185. You did have $842 remaining in your supplemental dental allowance, which the Plan has paid. However, you are responsible for the amount that exceeds this allowance.
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, there is a maximum allowance of $3,000 per year for covered services. The Plan has provided documentation that the full allowed amount has been paid for the year. Therefore, we decided that the Plan does not have to fully pay for the tooth extraction (D7210) provided on December 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided from March 27, 2019, to March 31, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim was received past the allowed timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services provided was not filed until June 10, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided from March 27, 2019, to March 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary. The Plan
denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 9, 2020, to November 12, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The Plan denied your request. The Plan says that the enrollee could have been treated in observation.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care would span two midnights. The enrollee was transferred to the hospital because they did not have the paperwork showing the family did not want intervention and she was admitted. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 9, 2020, to November 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgery you had at an outpatient
hospital facility on July 10, 2020.
You asked the Plan to waive the coinsurance for the outpatient surgery. You say that you thought your
insurance would cover you. You said that you cannot afford this amount because you are in the prescription
drug donut hole. The Plan denied your request. The Plan says you were charged this coinsurance correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for outpatient surgery at an outpatient hospital facility.
You have been asked to pay 20% coinsurance for the outpatient surgery. 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 you had at an outpatient hospital facility on July 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 19, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics.
The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on October 19, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 19,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection and an office visit provided by a participating provider.

You asked the Plan to waive the copayment for an injection and an office visit. You say that you do not feel like you should owe $60 every time you get this injection. The Plan denied your request. The Plan says the correct copayments have 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 $50 copayment for Medicare Part B prescription drugs/in-network and a $10 copayment for vision care/in-network.

You have been asked to pay a $50 copayment for an injection provided by a physician and a $10 copayment for an office visit. The total amount you are being asked to pay is $60 ($10 + $50 = $60). An injection falls within the Medicare Part B prescription drugs/in-network benefit category and an office visit falls within the vision care/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 an injection and an office visit provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost for the eyewear provided on November 20, 2020, which included progressive lenses (V2781), anti-reflective coating (V2750), polycarbonate lenses (V2784) and a deluxe lens feature (V2702).
You asked the Plan to pay the full cost for the eyewear. The Plan denied your request. The Plan says you met your $150 annual maximum allowance for eyewear. The Plan paid their maximum amount for the glasses, but you are responsible for the leftover cost per your contract.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to $150 annually. We looked at the file and the Plan's rules. The Plan provided documentation that they have paid the maximum allowance for the glasses as agreed upon in the contract. Therefore, we decided that the Plan does not have to
pay the full cost for the eyewear provided on November 20, 2020, which included progressive lenses (V2781), anti-reflective coating (V2750), polycarbonate lenses (V2784) and a deluxe lens feature (V2702).
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 continued services. The Plan denied your request. The Plan says the enrollee is dependent and failing to progress.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. Continued SNF services beyond February 19, 2021, were requested. 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 continued services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a minimal assist level for bed ambulation, and dependent for transfers. She required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. She does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the occlusal guard (D9940) and mepivacaine
HCl/10 ml injection (J0670) provided from January 9, 2020, to July 15, 2020.
You asked the Plan to reimburse you for the dental services. You say that the treatments were done to treat a
medical issue of facial tendon. The Plan denied your request. The Plan says the provider in this case is out of
network. The Plan also says that dental services that you receive out of network 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, dental services that you receive out of
network are not covered. Additionally, the services you received are not among those covered under this
benefit. Therefore, we decided that the Plan does not have to reimburse you for the occlusal guard (D9940) and
mepivacaine HCl/10 ml injection (J0670) provided from January 9, 2020, to July 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter (E0118).
You asked the Plan to pre-approve a knee scooter. You say that you need this to keep weight off your foot. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that DME MAC medical directors have reviewed information about the products billed using E0118. The determination is that there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for these products. We looked at the file and Medicare rules. The requested item has not been established as safe and effective. Based on this information, we decided that Medicare rules for coverage of a knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter (E0118).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Terbinafine 250 mg tablet.
You asked the Plan to pre-approve Terbinafine. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
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 Terbinafine 250 mg tablet.
Benefits for Terbinafine 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic imaging provided on August 19, 2020, by an
OON provider.
You asked the Plan to pay for diagnostic imaging. You say that you would like this claim reprocessed and paid.
The Plan denied your request. The Plan says prior authorization was not obtained for these services by a
participating provider.
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 diagnostic imaging provided on August 19, 2020,
by an OON provider.