Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, prophylaxis, topical application of fluoride varnish, and complete series of intraoral x-rays provided by an OON dentist on February 13, 2020.You asked the Plan to pay forthe comprehensive oral evaluation, prophylaxis, topical application of fluoride varnish, and complete series of intraoral x-rays. You say that your dental office did not know that the treating provider was non-participating with your plan. You also say that the office told you that they have never had problems with your insurance plan in the past.The Plan denied your request. The Plan says the treating provider is not a participating provider with your Plan network. The Plan also says that your plan does not cover services done by non-participating providers.Medicare generally does not cover dentalservices. 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 arenot covered when they are received by an OON provider.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation, prophylaxis, topical application of fluoride varnish, and complete series of intraoral x-rays provided by an OON dentist on February 13, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on December 4, 2019.
You asked the Plan to waive the copayment for the abdominal ultrasound. You say that you have had this same test done in the past and were not billed in the past. 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 day for Medicare-covered diagnostic radiology services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the ultrasound. You have been asked to pay a $249.90 copayment for the abdominal ultrasound. The abdominal ultrasound 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 the abdominal ultrasound provided on December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a below the knee prosthetic sheath (L8400), diabetic shoe for density insert (A5500), shoe insert (L5000), and prosthetic sock (L8420) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a below the knee prosthetic sheath, diabetic shoe for density insert, shoe insert, and prosthetic sock to be provided by an OON provider. You say that the items are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these items. Therefore, coverage criteria has not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a below the knee prosthetic sheath (L8400), diabetic shoe for density insert (A5500), shoe insert (L5000), and prosthetic sock (L8420) to be provided by an out of network (OON) provider
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to waive the copayment for the inpatient skilled nursing facility (SNF) care provided November 1, 2019 to November 26, 2019.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that the copayment has been applied correctly to the inpatient skilled nursing care provided.
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 does not clearly disclose when the $0 copayment applies vs. the $25 copayment for inpatient skilled nursing facility care, for days 21-100.
We looked at your contract with the Plan. You have been asked to pay a $475 copayment ($25 copayment per day x 19 days) for inpatient skilled nursing facility care. We do not see where the Plan contract indicates that you must pay a $25 copayment per day, for inpatient skilled nursing facility care, for days 21-100. The Plan contract does not clearly disclose when the $0 copayment applies vs. the $25 copayment for inpatient skilled nursing facility care, for days 21-100. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for the inpatient skilled nursing facility (SNF) care provided November 1, 2019 to November 26, 2019.
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 waive the coinsurance for the inpatient stay provided from December 10, 2019 through December 12, 2019.
You asked the Plan to waive the coinsurance for the inpatient stay. You say that you did not get the services that are being billed. You say that the charges are excessive. The Plan denied your request. The Plan says the coinsurance 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 10% of the total cost per admission at an in-network hospital. You have been asked to pay $514.18, which is 10% of the allowed amount for the inpatient stay. The allowed amount is $5,141.82 (10% x $5,141.82 = $514.18). The inpatient 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 coinsurance for the inpatient stay provided from December 10, 2019 through December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist/hand orthosis provided on January 14, 2020.
You asked the Plan to pay for the wrist/hand orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code L3916 is wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf. We find that CPT code L3916 is not supported in the medical record. Specifically, the documentation submitted did not indicate that the provider discussed the need for the billed supply code. Based on this information, we decided that Medicare rules for coverage of the wrist/hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the wrist/hand orthosis provided on January 14, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Beautyrest Hybrid Plush Mattress Firm Bed provided on October 23, 2019 from an out of network provider.
You asked the Plan to reimburse you for the bed. You say that the bed is medically necessary. The Plan denied your request. The Plan says you did not request prior authorization.
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 reimburse you 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 at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to reimburse you for these items. Therefore, we decided that the Plan does not have to reimburse you for the Beautyrest Hybrid Plush Mattress Firm Bed provided on October 23, 2019 from an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D1999 x 3) provided from April 13, 2019 to November 2, 2019.
You asked the Plan to reimburse you for the dental services. You say that you have a disease called peritonitis. You say that you have to go to the dentist 4 times per year for deep cleanings to save your teeth. You also say that you have been seeing this dentist for over 28 years. The Plan denied your request. The Plan says periodontal maintenance is not a covered service.
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, periodontal maintenance is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the periodontal maintenance (D1999 x 3) provided from April 13, 2019 to November 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (S9328) provided to the enrollee from August 14, 2019, to October 21, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code S9328 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (S9328) provided to the enrollee from August 14, 2019, to October 21, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the step therapy requirement is not met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral primary osteoarthritis of the knees. He has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Genvisc is 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 pre-approve Genvisc
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 September 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency for these 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 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 September 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190) provided to the enrollee on December 23, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the enrollee received the services in the facility during inpatient hospitalization, and payment for this service would be included in the part-A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99190 is "Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour." We find that CPT code 99190 is not supported in the medical record. Specifically, payment for this code is included in the payment to the facility. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190) provided to the enrollee on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 22, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 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 physician's services provided on November 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ultrasound provided on July 31, 2019.You asked the Plan to waive the copayment forthe ultrasound. You say that you were told this was a covered service and you should not be responsible for the copayment amount. 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 $45 copayment for in-network diagnostic procedures and tests. You have been asked to pay a $45 copayment for the ultrasound. The ultrasound 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 forthe ultrasound provided on July 31, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy.
You asked the Plan to pre-approve continued physical therapy. You say that you need physical therapy to walk again. The Plan denied your request. The Plan says you have met your therapy goals.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 continued physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you are making very slow progress in functional activities and at this point the therapies appear to be for maintenance rather than restorative. It is not expected that continued therapies will make a difference in your functional status. After two months of therapy you are still at max assist to dependent level except for bed mobility and upper body dressing which are at min assist. The documentation does not support that the requested services are part of a maintenance program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve continued physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
December 2, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration
because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating
room through the duration of the procedure. The Plan denied your request. The Plan says payment for this
service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier
other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the pump assembly and operation have not been met. Specifically, payment for this service is
included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore,
we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forspecialist visits provided on October 11, 2019 and October 18, 2019.You asked the Plan to waive the copayments forspecialist visits. You say that you disagree with the charges because you were misdiagnosed.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.Therules 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 specialist services.You received specialist visits on October 11, 2019 and October 18, 2019. Therefore, you are responsible to pay a $30 copayment per each visit. The total amount you owe is: $60.  You have been asked to pay the total copayment amount of $60 for specialist visits. Specialist visits fall 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 copayments forspecialist visits provided on October 11, 2019 and October 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided December 10, 2019 to December 31, 2019.You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services.The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of coverage were not met.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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and 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 the SNF services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided December 10, 2019to December 31, 2019.