Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay provided from May 26, 2020, to June 1, 2020.You asked the Plan to waive the copayment forthe inpatient hospital stay. You say that you believe that the charge is incorrect.The Plan denied your request. The Plan says the copayment applied correctly in this case.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 $345 copayment each day for days 1-5, $0 copayment for each additional day for inpatient hospital care. You have been asked to pay $345 copayment each day for days 1-5, $0 copayment for each additional day for the inpatient hospital stay. This service falls within the inpatient hospital 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 forthe inpatient hospital stay provided from May 26, 2020, to June 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0427, A0425) provided on June 11, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that ambulance transportation was not necessary. The Plan denied your request. The Plan says the copayment applied correctly in this case.

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 $220 copayment for ambulance services. 

You have been asked to pay a $220 copayment for the ambulance services. These 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 the ambulance services (A0427, A0425) provided on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete upper denture (D5110) and a complete lower denture (D5120).You asked the Plan to pre-approvethe dental items. You say that you cannot chew well with your current dentures. You say that they do not fit properly. You say that the dentist filed the dentures to try to adjust them and they still do not fit. You also say that you would like a whole new set of dentures.The Plan denied your request. The Plan says complete dentures are covered once every 5 plan years. The Plan says that the frequency limit has been reached.Medicare generally does not cover dental services. However, the Plan offersa 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 frequency limit of once every 5 plan years for complete dentures has been reached. The record shows that you received complete dentures previously on January 16, 2019.Therefore, we decided that the Plan does not have to pre-approvea complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible formedical services you received from, an out-of-network provider from May 5, 2020, to June 2, 2020.You asked the Plan to waive the deductible forthe medical services. You say that you did not know that out-of-network providers were being used.  You said that you need help with these bills.The Plan denied your request. The Plan says you had not yet met your deductible at the time of these services, so you were charged this amount correctly.The rules saya plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1000 deductible for covered medical services. You received these medical services from an out-of-network provider.  Your Evidence of Coverage clearly states that the annual $1,000 deductible applies to out-of-network services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible. This cost sharing is a contractual obligation that had not been met at the time the medical services were received on May 5, 2020 to June 2, 2020.Therefore, we decided that the Plan does not have to waive the deductible formedical services you received from an out-of-network provider from May 5, 2020, to June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments foroffice visits provided on July 13, 2020, and July 27, 2020.You asked the Plan to waive the copayments foroffice visits. You say that you have never paid a copayment for primary care provider visits in the past.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 $0 copayment for in-network primary care provider visits and a $15 copayment for out-of-network primary care provider visits.You had an office visit on July 13, 2020, with an out-of-network provider. Therefore, you are responsible to pay the $15 copayment. You had an office visit on July 27, 2020, with an out-of-network provider. Therefore, you are responsible to pay the $15 copayment.The total amount you owe is: $30. You have been asked to pay the total copayment amount of $30 for office visits. Office visits fallwithin the physician/practitioner services, including doctor's office visits 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 contractualobligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments foroffice visits provided on July 13, 2020, and July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forarthrocentesis provided on June 1, 2020.You asked the Plan to waive the copayment forarthrocentesis. You say that you just received an injection and were not informed that it was considered a surgical procedure.The Plan denied your request. The Plan says the claims were processed correctly and youare 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 $500 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay the allowed amount of $386.79, which is less than the $500 copayment for arthrocentesis. Arthrocentesis 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 forarthrocentesis provided on June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on January 17, 2020.
You asked the Plan to pay for the dental services. You say that you received approval for these services prior to receiving them. You say that the first page of your predetermination letter stated that the services would be covered under your 2019 benefit coverage. You say that the letter is valid until January 21, 2020. You also say that the services should be covered. The Plan denied your request. The Plan says the crown is not listed as a covered service. The Plan says core build up is not listed as a covered service. The Plan also says dental services not listed 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. The record shows that page 2 of the predetermination letter states that benefits will be based on the allowance in force at the time the claim is submitted. Since the claim was submitted in 2020, the services were processed based on the 2020 benefits. Therefore, we decided that the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on January 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontics (D6242) for teeth #11 and 12, and the retainer crown (D6752) for tooth #13. You asked the Plan to pre-approve the dental services. You say that you are not getting these services for aesthetic, but for your health. You also say that you cannot afford to pay for these. The Plan denied your request. The Plan says there is a maximum benefit of $2,500 for comprehensive dental services. The Plan says that the maximum benefit has been reached. 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 maximum benefit of $2,500 for comprehensive dental services has been reached. The record shows that the Plan approved $415 for pontics for teeth #6, 7, 8 and 9, $410 for tooth #10, and $415 for the retainer crown for tooth #5, thus reaching the maximum benefit. Therefore, we decided that the Plan does not have to pre-approve the pontics (D6242) for teeth #11 and 12, and the retainer crown (D6752) for tooth #13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore build up (D2950) for teeth # 9, 10, and 18.You asked the Plan to pre-approvethe core build up. You say that the services are necessary.The Plandenied your request. The Plan says core build up is not listed as a covered service. The Plan also says that any services not listed 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-approvecore build up (D2950) for teeth # 9, 10, and 18.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction services provided on September 11, 2020.
You asked the Plan to pay for eye refraction services. You say that these services should be covered by the
Plan. The Plan denied your request. The Plan says eye refraction services are only covered by the Plan during a
routine vision check. The Plan says that based on the claim and the records provided, this was not a routine
vison check.
Medicare does not cover refraction services. The Plan only covers refraction services for a routine eye exam.
The provider did not bill this service as a routine eye exam. Therefore, we decided that the Plan does not have
to pay for eye refraction services provided on September 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora diagnostic mammogram provided on June 25, 2020.You asked the Plan to waive the copayment fora diagnostic mammogram. You say that you disagree with the charges because you feel that the mammogram should be fully covered.The Plan denied your request. The Plan says the claims wereprocessed 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 and tests.The medical records show that you received a diagnostic mammogram on June 25, 2020. Therefore, you are responsible to pay the $50 copayment.  You have been asked to pay a $50 copayment for a diagnostic mammogram. A diagnostic mammogram 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 fora diagnostic mammogram provided on June 25, 2020.
Appeal type: Testing
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay 20% coinsurance for radiological diagnostic services. You can find this information on page 4-39 of the Plan's 2020 EOC.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel rendered on October 27, 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. Medicare rules say that NGS panels are covered when specific criteria are met. 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 has a diagnosis of stage IV renal cell carcinoma metastatic to lung and bone. He has had evidence of disease progression while on multiple forms of therapy. While the enrollee has recurrent, relapsed metastatic stage IV renal cancer; and has decided to seek further cancer treatment, there is no documentation that the diagnostic laboratory test using NGS has an FDA-approved or -cleared indication for use in renal cell cancer. The testing was therefore not 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 targeted genomic sequence analysis panel rendered on October 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approved interspinous process distraction device (CPT Codes: C1821, 22869, 22870).You asked the Plan to pre-approve the device. You say that the device is necessary.The Plan denied your request. The Plan says the device is not 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 determine if the Plan was correct in denying the request to pre-approve the device. 

Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy.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 device have not been met.Therefore, we decided that the Plan does not have to pre-approve interspinous process distraction device (CPT Codes: C1821, 22869, 22870)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveremoval of multiple dental implants, bone grafting, and replacement of dental implants, and anesthesia and facility charges for your dental procedures (CPT Code 41899) to be provided by an out-of-network provider.

You asked the Plan to pre-approvethe dental services. You say that you have difficulty eating due to pain in teeth and you are trying to prevent further infection.The Plan denied your request. The Plan says the services are not a covered benefit under the plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services are not covered by the Plan or Medicare. Furthermore, 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 requirethe Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approveremoval of multiple dental implants, bone grafting, and replacement of dental implants, and anesthesia and facility charges for your dental procedures (CPT Code 41899) to be provided by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial and subsequent hospital care provided from January 15, 2020, to January 21, 2020.You asked the Plan to pay forthe inpatient hospital services. You say that the enrollee was discharged from hospice prior to when the services were rendered.The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verifythe member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.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 January 15, 2020. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe initial and subsequent hospital care provided from January 15, 2020, to January 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a behavioral health inpatient admission provided.You asked the Plan to pay for the behavioral health inpatient admission. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.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 Plandid not pre-approve the servicesat 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 a behavioral health inpatient admission provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you appear to be unstable for transfer and requires additional acute care services which can safely be performed at the current facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already covered and available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered when you are more stable and treatment has completed. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services provided by an out of network (OON) provider.
You asked the Plan to pay for telehealth services. You say that due to Covid-19 you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 telehealth services provided by an out of network (OON) provider.