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

We decided that the Plan does not have to waive the copayments for the SNF stay provided from May 23, 2019 to June 20, 2019.You asked the Plan to waive the copayments for the SNF stay. You say that you did not want to stay longer than 21 days. You say you could not afford to pay $172 a  day.The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $0 copayment per day for days 1-20 and a $172 copayment per day for days 21-100. You have been asked to pay a $$1,376 for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. See chart below.Dates of ServiceServiceCopayment per DaySNF DaysNumber of DaysMember LiabilityMay 23, 2019 to May 31, 2019SNF stay$01-99$0June 1, 2019 to June 11, 2019SNF stay$010-2011$0June 12, 2019 to June 20, 2019SNF stay$17221-288$1,376Total$1,376. 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 for the SNF stay provided from May 23, 2019 to June 20, 2019.Your complaint that you were treated poorly 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation provided on November 6, 2019.You asked the Plan to pay forthe comprehensive oral evaluation. You say that you believe the exam should be covered because the two exams performed on October 10, 2019 were not actual exams. You also say that all the provider did during these exams was look into your mouth and then refer you to another provider.The Plan denied your request. The Plansays this service is allowed two times in a benefit year. The Plan also says that they made payment for two exams on October 10, 2019 and you were not eligible for an additional exam.Medicare generally does not cover dental services. However, the Planoffers 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, preventive oral examinations are limited to two per calendar year. The record shows that you received two problem focused limited oral evaluations on October 10, 2019 and your preventive oral examinations benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation provided on November 6, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided from October 26, 2019 through October 27, 2019.
You asked the Plan to waive the copayment for the ER visit. You say that you were admitted right away. You say that you should not have been charged. 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 to be an inpatient, your provider must write an order to admit you formally as an inpatient of the hospital. Even if you stay in the hospital overnight, you might still be considered an "outpatient." Your contract with the Plan clearly says that you must pay a $100 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $100 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were admitted to outpatient observation. 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 ER visit provided from October 26, 2019 through October 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 2, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 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 medical services provided to the enrollee by an out-of-network provider on October 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on September 17, 2019 by a provider who opted out of Medicare.
You asked the Plan to pay for the dental services. You say that the federal government told you not to pay. The Plan denied your request. The Plan says the dental office opted out of Medicare December 30, 2015.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the dental services have not been met. These services are denied because the provider opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided on September 17, 2019 by a provider who opted out of Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on October 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for home health services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was 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 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 home health services provided on October 22, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Moh's surgery provided on August 26, 2019.
You asked the Plan to waive the copayment for the Moh's surgery. You say that your copayment should be refunded because you believe the Moh's procedure was done in the doctor's office. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $250 copayment per visit, per provider, per day for outpatient surgery performed in an ambulatory surgical center. You have been asked to pay a $250 copayment for the Moh's surgery. The Moh's surgery falls within the "Outpatient surgery, including services provided at a hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows that the provider is an ambulatory surgery center and that you would be charged by the ambulatory surgical center.
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 Moh's surgery provided on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on November 6, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not
contracted.
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 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 medical services provided to the enrollee by an out-of-network provider
on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on November 21, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 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 medical services provided to the enrollee by an out-of-network provider
on November 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on December 11, 2019.You asked the Plan to waive the copayment for a CT scan. You say that you cannot afford 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 $275 copayment for each advanced imaging service. You have been asked to pay a $275 copayment for a CT scan. A CT scan falls 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 a CT scan provided on December 11, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pay forhome health services provided to the enrollee from February 2, 2019 to April 2, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysa valid HIPPS code and RAP are required for processing.The Plan must follow Medicare rules. Medicare rules say that home health services must be billed and coded correctly. The home health claim in this case did not contain the correct items required for processing. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forhome health services provided to the enrollee from February 2, 2019 to April 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe orthoses provided on November 26, 2019.You askedthe Plan to pay forthe knee orthoses (L1833) and suspension sleeves (L2397). You say that the claim was submitted correctlyand should be paid.The Plan denied your request. The Plan says it is not appropriate to report left and right diagnosis codes when a bilateral code is availableand a corrected claim can be submitted.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate ICD code.We find the claimshould have the bilateral code. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met.Therefore, we decided that the Plan does not have to pay forthe orthoses provided on November 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea grab bar.You asked the Plan to pre-approvea grab bar. You say that the item is necessary to help prevent you from falling when taking a bath.The Plan denied your request. The Plan says the item is not primarily medical in nature. Therefore, coverage criteria has not been met.The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriatein this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea grab bar.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on November 5, 2019 to November 7, 2019.
You asked the Plan to waive the copayment for specialist services. You say that you do not agree with these charges. 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 $40 copayment for physician/practitioner services/specialist services. You have been asked to pay a $40 copayment for specialist services. Specialist services fall within the physician/practitioner services/specialist 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 specialist services provided on November 5, 2019 to November 7, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran emergency room visit provided on December 13, 2019.You asked the Plan to waive the copayment foran emergency room visit. You say that the doctor told you to go to the ER after sitting in his office for an hour. You say that you do not think it is fair to be charged for an emergency room visit.The Plandenied 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. Since care was provided in an emergency room setting, the correct copayment has been applied. An emergency room visit falls within the emergency care 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 foran emergency room visit provided on December 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing rendered to enrollee on October 23, 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 testing is not covered.The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 testing rendered to enrollee on October 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetotal knee arthroplasty revision.You asked the Plan to pre-approvetotal knee arthroplasty revision. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.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 determineif the Plan was correct in denying the request to pre-approve total knee arthroplasty revision. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with difficulties with the right total knee replacement. The enrollee complains of right knee discomfort, instability, giving out, popping, and clicking. Clinical exam findings have documented limited flexion, hyperlaxity in extension, and clinical findings of laxity. X-ray findings are reported to show optimal mechanical alignment and no obvious hardware complications. Body mass index was reported to be 48, which was a prohibitive risk. Given the general risks associated with revision total knee replacement and the increased risks in an obese diabetic smoking patient, this request is not supported by current medical evidence at this time. Therefore, this enrollee's diagnosis, condition, and/or symptoms would not meet Medicare criteria to supportrevision total knee arthroplasty at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of total knee arthroplasty revision have not been met.Therefore, we decided that the Plan does not have to pre-approvetotal knee arthroplasty revision.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran electrocardiogram provided on December 23, 2019.You asked the Plan to waive the copayment foran electrocardiogram. You say that you were told that you would only owe the office visit copayment.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 $50 copayment for diagnostic procedures/tests. You have been asked to pay the allowed amount of $48.20, which is less than the $50 copayment for an electrocardiogram. An electrocardiogram falls 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 foran electrocardiogram provided on December 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that the whole staff has been very efficient in managing your care. The Plan denied your request. The Plan says your benefits require the use of in-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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve vision services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKeytruda (J9271).You asked the Plan to pre-approveKeytruda. You say that the requested medication is necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found compendia notes the requested medication has orphan drug approval for individuals with cervical cancer with tumors that express PD-L1. Submitted documentation does not outline this criterion. Medical necessity cannot be determined.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met.Therefore, we decided that the Plan does not have to pre-approveKeytruda (J9271).