Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe outpatient rehabilitation services rendered from July 24, 2020 to August 31, 2020.You asked the Plan to waive the copayments forthese services. You say that you were referred by your cardiologist.The Plan denied your request. The Plan says the copayments were 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 $20 copayment for in-network outpatient rehabilitation services. Review of the file shows that you had outpatient rehabilitation services for 12 dates of service from July 24, 2020 to August 31, 2020. You have been asked to pay a $20 copayment per date of service for these services, for a total of $240. These services fall within the in-network 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 copayments forthe outpatient rehabilitation services rendered from July 24, 2020 to August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
June 11, 2020.
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 enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The 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 out of network physician
services provided to the enrollee on June 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDupixent inj 300/2 mL.You asked the Plan to pre-approveDupixent. You say that this service is medically necessary.The Plandenied your request. The Plan says drug coverage is limited only to those drugs 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-approveDupixent inj 300/2 mL.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe specialist services rendered on June 29, 2020 to September 3, 2020.You asked the Plan to waive the copayments forthese services. You say that you never used to have a copayment.The Plan denied your request. The Plan says the copayments were 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 $30 copayment for each specialist visit for Medicare-covered benefits. Review of the file shows that you received specialist services on four dates of service from June 29, 2020 to September 3, 2020. You have been asked to pay a $30 copayment per date of service for these services, for a total of $120. These services fall within the specialist visit for Medicare-covered benefits 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 copayments forthe specialist services rendered on June 29, 2020 to September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing foran injection of hyaluronan and specialistadministration service provided on August 28, 2020.You asked the Plan to waive the cost-sharing forinjection and specialist visit. You say that you only paid $28.44 for these services previously.The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.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 saysthat you must pay 20% coinsurance for injection and $35 copayment for specialist visit. The allowed amount of the injection is $151.46, resulting in a coinsurance amount of $30.29. Therefore, your total cost-sharing responsibility is $65.29.You have been asked to pay 20% coinsurance for injection and $35 copayment for specialist visit. Injection and specialist visit fall within the "Medicare Part B Prescription Drugs" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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-sharing foran injection of hyaluronan and specialist administration service provided on August 28, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, spine, lumbosacral (72100) provided on September 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the x-ray services. You say that having the x-rays to see the condition was necessary. If you can't pay for something that is needed why does a person have insurance. If this is a problem you may look into a different insurance. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor per the plan benefits. Enrollee's must receive their medical services from an in-network provider.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for radiologic examination, spine, lumbosacral (72100) provided on September 1, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a commode chair.

You asked the Plan to pre-approve a commode chair. You say that this is medically necessary. The Plan denied your request. The Plan says that notes do not show you meet criteria for a commode chair.

The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are confined to a bed or room. 

The file does not show that you are confined to a bed or room as defined by Medicare rules. Therefore, we decided that the Plan does not have to pre-approve a commode chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two core buildups, including any pins when required (D2950 x2) and an endodontic therapy (D3310).

You asked the Plan to pre-approve the core buildups and endodontic therapy. You say that you need these services for your dentures to attach to. 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 pre-approve two core buildups, including any pins when required (D2950 x2) and an endodontic therapy (D3310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a breast prosthesis and mastectomy bras for the enrollee to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve these services. You say that these items are medically necessary. The Plan denied your request. The Plan says that there are in network providers available.

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 breast prosthesis and mastectomy bras for the enrollee to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric services rendered from April 6, 2019 to May 6, 2019.
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 the services were not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with adjustment disorder with mixed disturbance and dysthymic disorder. Based on the submitted records, it was not expected this enrollee would improve in a reasonable period of time, as she did not have dangerousness to self or others, auditory or visual hallucinations, or behaviors threatening acute safety. She was cooperative and compliant with treatment. It does not appear that active treatment was taking place. The records do not support that the services were reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric services rendered from April 6, 2019 to May 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture and complete mandibular denture provided on April 22, 2020, and May 13, 2020.
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that you feel you should not be charged for the dentures because they did not fit correctly, and you cannot use them. The Plan denied your request. The Plan says the coinsurance that you are being charged has been applied correctly.
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 complete maxillary denture and complete mandibular denture provided on April 22, 2020, and May 13, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for hearing aids provided on February 7, 2020.
You asked the Plan to pay for hearing aids. You say that you reimbursed the enrollee for these charges, so the Plan should issue reimbursement to you. The Plan denied your request. The Plan says that the denial of payment for these hearing aids is correct, because these hearing aids are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays for hearing aids only up to a $1,000 allowance for hearing aids every 3 years, combined in-network and out-of-network. We looked at the file, the Plan's rules, and Medicare rules. The Plan has denied payment on the basis that hearing aids are only covered by the Plan when ordered directly from a Plan contracted hearing aid vendor; however, the Plan contract clearly states that the hearing aid benefit is a combined in-network and out-of-network benefit. The Plan has not shown that the $1,000 hearing aid allowance every 3 years had been exhausted on this date of service. Based on this information, we decided that the Plan's rules for coverage of hearing aids have been met. Therefore, we decided that the Plan has to pay for hearing aids provided on February 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3310).
You asked the Plan to pre-approve the endodontic therapy. You say that you are experiencing severe pain, and need this procedure done immediately. The Plan denied your request. The Plan says this service is 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 pre-approve endodontic therapy (D3310).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Telehealth originating site facility fee services coded Q3014 provided on July 2, 2020.
You asked the Plan to pay for the Telehealth originating site facility fee services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services rendered are not payable.
The Plan must follow Medicare rules. The rules say that Medicare covers services in freestanding emergency departments only if the emergency clinic is affiliated with a hospital. We looked at the file and Medicare rules. Review of the file shows that the provider was a non-Medicare approved/certified freestanding emergency facility. Based on this information, we decided that Medicare rules for coverage of the Telehealth originating site facility fee services have not been met. Therefore, we decided that the Plan does not have to pay for the Telehealth originating site facility fee services coded Q3014 provided on July 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the abdomen and pelvis (74178) provided on September 6, 2018.
You asked the Plan to pay for the CT of the abdomen and pelvis. You say that you would like reconsideration because this claim was initially billed to the VA. The Plan denied your request. The Plan says this claim was not received within one year of the date of service.
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 CT of the abdomen and pelvis was not filed until September 14, 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 CT of the abdomen and pelvis (74178) provided on September 6, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post stabilization inpatient care provided to the enrollee from 11:35 AM on June 5, 2020 through June 6, 2020.
You asked the Plan to pay for the post stabilization inpatient care. You say that these services were medically necessary. The Plan denied your request. The Plan says that the enrollee was stable for transfer.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 the post stabilization inpatient care. Our reviewer says that inpatient care was not medically reasonable and necessary for the enrollee in this case. By 11:34 AM on June 5, 2020, the enrollee was stable for ambulance transport with monitoring to a Plan facility. The enrollee remained hemodynamically stable and deemed stable for discharge home by IR Cardiology. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. Our physician reviewer found that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility. 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 post stabilization inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the post stabilization inpatient care provided to the enrollee from 11:35 AM on June 5, 2020 through June 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgeries provided on July 29, 2020 and August 19, 2020.
You asked the Plan to waive the copayment for the outpatient surgeries. You say that you thought this would be covered under an office visit copayment. The Plan denied your request. The Plan says that you are responsible for the copayments.
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 $350 copayment per day for outpatient procedures and services, including, but not limited to, outpatient surgery performed in an outpatient hospital or ambulatory surgical center. You have been asked to pay two separate $350 copayments for the outpatient surgeries. The outpatient surgeries fall within the outpatient procedures and services, including, but not limited to, outpatient surgery performed in an outpatient hospital or ambulatory surgical center 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 outpatient surgeries provided on July 29, 2020 and August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital injection services provided August 5, 2020 to August 19, 2020.
You asked the Plan to waive the copayment for the outpatient services. You say that you disagree with the charges. You don't understand how you can be charged as an inpatient. You know that you need to pay but as an outpatient. The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied. The plan confirmed with the provider that services were performed in an outpatient hospital.
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 $300 copayment for each Medicare covered outpatient hospital service, including observation, outpatient surgery or procedure. You have been asked to pay $300 copayment for the outpatient services. The outpatient services 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 outpatient hospital injection services provided August 5, 2020 to August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient visit provided to the enrollee on September 21, 2020.
You asked the Plan to pre-approve the visit. You say that this should be paid for. The Plan denied your request. The Plan says Medicare rules say that health plans can require enrollees to get care from network providers.
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 an outpatient visit provided to the enrollee on September 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair.
You asked the Plan to pre-approve a recliner chair. You say that you have a sleeping disorder and the requested reclining chair could be elevated to help with eating and to prevent further pedal edema. The Plan denied your request. The Plan says a recliner chair is furniture and is not used to care for a medical problem.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a recliner chair.