Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe SNF stay provided from March 1, 2020 to March 31, 2020.You asked the Plan to waive the copayments forthe SNF stay. You say that your father should not be responsible for the copayment. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day, per admission for days 1-20 and a $160 copayment per day, per admission for days 21-100. The enrollee has been asked to pay a $2,400 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments forthe SNF stay provided from March 1, 2020 to March 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on November 22, 2019.You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the records show that the enrollee's evaluation did not take place at a qualifying originating site.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The Tracking Numbers do not match and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on November 22, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the individual therapy visits provided from January 8, 2019 to March 12, 2020.
You asked the Plan to waive the copayments for the individual therapy visits. You say that you cannot afford these copayments. 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 $30 copayment for each individual or group therapy visit in 2019 and a $40 copayment per individual or group therapy visit in 2020. You have been asked to pay a $30 copayment for each of the individual therapy visits in 2019 and a $40 copayment for each of the individual therapy visits in 2020. The individual therapy visits fall within the "Outpatient mental health 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 copayments for individual therapy visits provided from January 8, 2019 to March 12, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
March 6, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you were admitted into
the hospital within 72 hours for the same condition. You say your copayment should be waived. 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 $90
copayment for each Medicare-covered emergency room visit in-network and out-of-network.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" benefit category. The record shows you were transferred to a different hospital for
the inpatient treatment.
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 emergency room visit provided on March 6, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continued inpatient substance abuse detoxification services.You asked the Plan to pre-approve continued inpatient substance abuse detoxification services. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says that the services are not necessary.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. The plan did not provide sufficient medical records in order to determine if the enrollee meets Medicare criteria for continued inpatient substance abuse detoxification from May 26, 2020 to date of discharge. As the enrollee was admitted to an inpatient substance abuse program back on May 20, 2020, and the Plan did not send this appeal request to us until July 8, 2020, we sent a request for additional information to confirm the enrollee's discharge date and for complete medical records as the file only includes case notes and a treatment plan. The information provided by the Plan is insufficient to determine if the enrollee meets Medicare criteria for continued inpatient substance abuse detoxification services from May 26, 2020 and forward.Therefore, we decided that the Plan has to pre-approvecontinued inpatient substance abuse detoxification services.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's hospital stay has been long and complicated and her needs would be best met in the LTACH setting. The Plan denied your request. The Plan says the enrollee's current hospital stay can continue on for as long as it is necessary for her to stabilize enough to go to a lower level of care.
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 the enrollee was admitted on April 9, 2020 due to heart and renal failure. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in the current acute care setting. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The prolonged hospital stay does not make LTACH care medically reasonable and necessary as the current facility is adequate. 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe oral evaluation, resin based composite, extraction and intraoral x-rays provided on January 21, 2020.You asked the Plan to pay forthe oral evaluation, resin based composite, extraction and intraoral x-rays. You say that you were under the impression that the provider would call to see if the services would be covered by insurance. You say that you were not informed up front about network status.The Plan denied your request. The Plan says out-of-network dental services are 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, out-of-network dentalservices are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe oral evaluation, resin based composite, extraction and intraoral x-rays provided on January 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ambulance transport (A0426) provided February 15, 2020.You asked the Plan to waive the copayment forthe ambulance transport. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost sharing was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for Ambulance Services. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls 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 foran ambulance transport (A0426) provided February 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care, per day (99309) provided on August 13, 2018.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the service was renderedby an out of network provider, without prior authorization.The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The service at issue in this appeal wasnot provided in an emergency or urgent care situation. The service wasnot provided by the Planor through arrangements with them.Therefore, we decided that the Plan does not have to pay forthe subsequent nursing facility care, per day (99309) provided on August 13, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral surgery consultation and follow-up visits.
You asked the Plan to pre-approve the oral surgery consultation and follow-up visits. You say that the enrollee in in pain, cannot eat, bleeds, and needs to see this specialist as soon as possible. The Plan denied your request. The Plan says the enrollee has no supplemental plan benefit for the requested dental services.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve oral surgery consultation and follow-up visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the virtual or telehealth consultation (99441) provided May 7, 2020.
You asked the Plan to waive the copayment for the telehealth consultation. You say that you are appealing the charge of $35 for a phone conversation with your eye doctor as it cannot replace an actual examination by simply answering a few questions. The Plan denied your request. The Plan says the correct copayment was applied per the plan benefits.
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 $35 copay for Medicare covered specialist services for physician/practitioner services, including doctor's office visits. You have been asked to pay $35 copay for the telehealth consultation. The telehealth consultation falls within 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 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 virtual or telehealth consultation (99441) provided May 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954)
provided on March 11, 2020.
You asked the Plan to pay for the post and core. You say that you had a broken tooth and the dentist needed to
build the tooth up before he could place the crown. The Plan denied your request. The Plan says this service is
not covered under your benefit plan.
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
prefabricated post and core in addition to crown (D2954) provided on March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam (D0120) prophylaxis (D1110) intraoral - periapical first x-ray (D0274) provided February 21, 2020 from an out of network provider.
You asked the Plan to pay for the dental services. You say that prior to going to your dentist you checked for in-network dentists and there were none within 50 miles of your home. You are appealing and request reimbursement. The Plan denied your request. The Plan says enrollee's must receive dental services from an in-network provider.
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. Services rendered by an out of network provider is not covered. The plan confirmed there an in-network providers within 10 miles of your residence. 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 when received out of network. Therefore, we decided that the Plan does not have to pay for the periodic oral exam (D0120) prophylaxis (D1110) intraoral - periapical first x-ray (D0274) provided February 21, 2020 from an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's needs can be met in skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for planned T11-L1 decompression/fusion. There were no post-operative complications and there are no complex medical or nursing needs which require ongoing inpatient care. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The documentation does not support a need for multidisciplinary intensive rehabilitation. Appropriate physical and occupational therapy can be provided in a lower level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested SNF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for admission to a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with Parkinson's disease who presented to the emergency room for acute mental status and sub sternal chest pain after recent SNF discharge to an assisted living facility. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Her lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a contact guard to minimal assist level with functional mobility including gait to 80 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on February 11, 2020.You asked the Plan to pay forthe periodic oral evaluation and prophylaxis. You say that your plan has a dental allowance of $850 per year.The Plan denied your request. The Plan says the treating provider opted out of Medicare effective November 10, 2015 through November 10, 2021. The Plan says that they cannot issue payment for services performed by an opt out provider.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on February 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309)
provided on May 25, 2018.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
The rules say that except for emergency and urgently needed services, plans are not required to make payments
for any services received by enrollees that are not provided directly by the Plan or through arrangements made
by the Plan.
The service at issue in this appeal was not provided in an emergency or urgent care situation. The service was
not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have
to pay for the subsequent nursing facility care, per day (99309) provided on May 25, 2018.