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

We decided that the Plan does not have to waive the copayment for the ultrasound provided on March 23, 2020, the office visit provided on November 30, 2020 and the x-ray provided on December 28, 2020.
You asked the Plan to waive the copayment for the ultrasound, office visit and x-ray. You say that there is no copayment for a specialist x-ray. The Plan denied your request. The Plan says the copayments 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 $100 copayment for all other diagnostic tests and a $35 copayment for visits to a specialist. You have been asked to pay a total of $96.56 for the ultrasound, office visit and x-ray.
The ultrasound and x-ray fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The office visit 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 ultrasound provided on March 23, 2020, the office visit provided on November 30, 2020 and the x-ray provided on December 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from November 4, 2020, to November 9, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the provider should be responsible for the charges because they messed up a procedure. 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 $220 copayment for days 1-8 for inpatient hospital care. You received an inpatient hospital stay from November 4, 2020, to November 9, 2020. Therefore, you are responsible to pay a $220 copayment for days 1-5 (November 4, 2020, to November 8, 2020). $220 (copayment) x 5 (inpatient days) = $1,100. You have been asked to pay the total copayment amount of $1,100 for an inpatient hospital stay. An inpatient hospital stay 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 for an inpatient hospital stay provided from November 4, 2020, to November 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional services performed by a qualified
occupational therapist in the home health or hospice setting (G0152).
You asked the Plan to pre-approve the additional services performed by a qualified occupational therapist. You
say that the enrollee requires training with self-care and functional transfers. The Plan denied your request. The
Plan says the enrollee does not meet criteria for additional visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 additional services performed by a
qualified occupational therapist. Our reviewer says that the requested home health services are not medically
necessary. Our physician reviewer found the documentation does not support that the enrollee requires
additional skilled rehab services to provide treatment that is medically necessary. Our reviewer found that the
enrollee does not require skilled rehab services to effectively provide treatment, care, and/or services in order
to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or
prevent deterioration. Our physician reviewer also found that the enrollee has been medically stable without
any recent exacerbations of chronic medical problems or hospitalizations.
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 additional services performed by a qualified occupational therapist have not
been met. Therefore, we decided that the Plan does not have to pre-approve additional services performed by a
qualified occupational therapist in the home health or hospice setting (G0152).
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.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires aggressive therapies for best outcome to recover in the shortest amount of time. The Plan denied your request. The Plan says the enrollee needs to stay in the hospital.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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. 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laryngoscopy provided on August 11, 2020.
You asked the Plan to waive the copayment for the laryngoscopy. You say that you were not at a hospital and the exam took place in an office exam room. You say that your benefits clearly state diagnostic exams have a $25 copayment. 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 you must pay a $260 copayment for Medicare-covered surgery or other services provided to you at an in-network ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $260 copayment for the laryngoscopy. The laryngoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The records show the laryngoscopy was billed by the hospital. 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 laryngoscopy provided on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the cardiac device evaluation provided on December 7, 2020.

You asked the Plan to waive the co-payment for the cardiac device evaluation. You say that this was an office visit to monitor your pacemaker. You say that there should be no co-payment for this service. The Plan denied your request. The Plan says the co-payment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 co-payment for provider and professional services at an in-network specialist's office.

You have been asked to pay a $45 co-payment for the cardiac device evaluation. The cardiac device evaluation 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 co-payment for the cardiac device evaluation provided on December 7, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the psychotherapy visits provided from October 14, 2020, to November 11, 2020.
You asked the Plan to waive the copayments for the psychotherapy visits. You say that according to your Annual Notice of Changes states that virtual medical visits have a $0 copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $40 copayment for each Medicare-covered in-network individual therapy session. You have been asked to pay a $40 copayment for each of the psychotherapy visits. The psychotherapy visits fall within the "Outpatient Mental Health Care" benefit category. The record shows you were billed code 90834 which is considered an outpatient psychiatry service. 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 psychotherapy visits provided from October 14, 2020, to November 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on October 26, 2020.

You asked the Plan to pay for foot orthotics. You say that your feet are deformed and cannot walk without orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames (V2020) received on October 15, 2020.

You asked the Plan to pay for frames. You say that you would like the Plan to pay for the item. The Plan denied your request. The Plan says the benefit maximum allowance had already been met.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to a $400 allowance, then you are responsible for paying the difference. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of frames have not been met. Specifically, the record shows that you had exhausted your eyewear benefit maximum of $400 and are therefore, responsible for paying the remainder. Therefore, we decided that the Plan does not have to pay for frames (V2020) received on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on December 1, 2020 by an out of network provider.
You asked the Plan to pay for the chiropractic services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization for the non-emergent services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 chiropractic services provided on December 1, 2020 by an out of network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on September 26, 2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 September 24, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services provided on September 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the PET 78815 provided on November 10, 2020.

You asked the Plan to pay for PET skull base to mid-thigh (78815). You say that the PET imaging was medically necessary. The Plan denied your request. The Plan says the diagnosis code submitted is not listed as an appropriate diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate diagnosis code.

We find that International Classification of Diseases (ICD-10) code C50.911 is not an appropriate diagnosis code for this PET imaging. Based on this information, we decided that Medicare rules for coverage of PET skull base to mid-thigh have not been met. Therefore, we decided that the Plan does not have to pay for the PET imaging provided on November 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from
January 6, 2021, to January 14, 2021.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you would like the
Plan to reconsider your request. The Plan denied your request. The Plan says you received physical therapy on
the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per your
contract with the Plan.
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 $35
copayment for Outpatient rehabilitation services.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received physical therapy
on January 6, 2021, January 9, 2021, January 12, 2021, and January 14, 2021. You have been asked to pay a
$35 copayment for each physical therapy visit. The physical therapy visits fall within the Outpatient
rehabilitation services benefit category. This means that you have been asked to pay the correct amounts 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
physical therapy visits provided from January 6, 2021, to January 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0481) provided June 29, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes 80307, & G0481 are not supported in the medical record. Specifically, the claim billed shows place of service 81, laboratory. The records show the specimen was obtained at place of service 11, office setting. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307, G0481) provided June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain provided on November 11, 2020.
You asked the Plan to pay for the emergency treatment of dental pain. You say that you do not understand why this service was not covered under your medical benefit. The Plan denied your request. The Plan says this service is not covered. The Plan also says that this service was dental related, and not among the list of covered dental services per your EOC.
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 palliative (emergency) treatment of dental pain provided on November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider
on June 1,2020 and June 2, 2020.

You asked the Plan to pay for laboratory services. You say that the medical records support treatment decisions
and the provider is seeking reconsideration. The Plan denied your request. The Plan says out-of-network
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 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 laboratory services provided by an out-of-network
provider on June 1,2020 and June 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the scaling and root planing (D4342) for the
lower left, lower right, and upper left quadrants.
You asked the Plan to pay the full amount for the dental services. You say that you have not used your annual
this year, but the denial shows that you did. You also say that your dentist recommended that you procedure be
done. The Plan denied your request. The Plan says each quarter you earn $750 towards the maximum annual
allowance of $3,000. The Plan says that the benefit amount has been exhausted.
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 and the services are listed as covered,
the quarterly benefit amount has been exhausted. The record shows that on the date of service in this case, you
had earned $750 of the annual maximum allowance. The Plan paid $750 towards the services provided on this
date of service. The Evidence of Coverage clearly states that coverage is based on the available balance on the
date of service. Therefore, we decided that the Plan does not have to pay the full amount for the scaling and
root planing (D4342) for the lower left, lower right, and upper left quadrants.