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

We decided that the Plan does not have to waive the copayment for the breast biopsy (19083) provided on February 15, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 clearly says that you must pay a $300 copayment for in-network Medicare-covered surgical services at an outpatient hospital or ambulatory surgical center.
You have been asked to pay a $300 copayment for the Medicare-covered surgical services provided at an outpatient 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 breast biopsy (19083) provided on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a right knee brace (L1833) and suspension sleeve (L2397) provided on March 25, 2021.
You asked the Plan to pay for a knee brace and suspension sleeve. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the requested items are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a knee brace and suspension sleeve. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. It is documented that the surgery to address the enrollee's pain occurred on June 7, 2017, and that "the surgery addressed the following: nephrectomy 3 years ago." The item coded L2397 (sleeve) is not separately payable when the base item is not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee brace and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for a right knee brace (L1833) and suspension sleeve (L2397) provided on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided on February 23, 2021.

You asked the Plan to waive the coinsurance for radiation therapy services. You say that you could have done surgery for free but was advised of radiation treatment. You say that you were never told there was 20% coinsurance. 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 20% coinsurance per visit for radiation therapy.

You have been asked to pay $63.65, which is 20% of the allowed amount for radiation therapy services. The allowed amount is $318.23 (20% x $318.23 = $63.65). Radiation therapy services fall 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 coinsurance for radiation therapy services provided on February 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on April 23, 2021.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that it was your understanding that this was a regular screening. You say you have had polyps removed in the past, but no samples were taken during this colonoscopy. 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 $275 copayment for Medicare-covered outpatient surgery for a surgical visit in an ambulatory surgical center.

You have been asked to pay a $275 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows personal history of polyps which makes the colonoscopy diagnostic in nature.

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 diagnostic colonoscopy provided on April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator provided from January 1, 2021 to March 1, 2021.

You asked the Plan to waive the coinsurance for the automatic external defibrillator. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. 
The Plan says you received durable medical equipment on the dates of service at issue in this appeal. The Plan says that the correct coinsurance has 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 20% coinsurance for Durable medical equipment. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an automatic external defibrillator on January 1, 2021, February 1, 2021, and March 1, 2021. You have been asked to pay a 20% coinsurance for the automatic external defibrillator, totaling $586.29 for each date of service. The automatic external defibrillator falls within the Durable medical equipment 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 automatic external defibrillator provided from January 1, 2021 to March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6059) provided on April 12, 2021.

You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain fused to metal crown. You say that you would like these services to be covered. The Plan denied your request. The Plan says this implant service is not a covered benefit under your 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 custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6059) provided on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance provided on February 1, 2021.
You asked the Plan to pay for periodontal maintenance. You say that you were previously saw this dentist and were reimbursed without any issues. You say that the same doctor provided the same service three times and the claim should be resolved. The Plan denied your request. The Plan says no payment may be made to a beneficiary for services provided by a physician or practitioner who has opted out of Medicare. The Plan also says that payment on the previous claims were made in error.
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 who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for periodontal maintenance provided on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on March 25, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you realize this is a one time a year benefit, but you did not receive this benefit in 2020. The Plan denied your request. The Plan says this service exceeds the frequency limitation in 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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on July 10, 2020 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on March 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the patient is currently in a homeless shelter where she remains at high risk for infection or injury. The Plan denied your request. The Plan says that the record does not show that the enrollee requires daily skilled nursing or skilled therapy in a SNF setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) and supplies provided on April 9, 2021.

You asked the Plan to pay for the CGM supplies. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the medical records submitted do not include evidence that the criteria were met in this case.

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 relevant medical records which support medical necessity for the supplies provided in this case. The most recent progress note is from a month before the CGM was ordered. This note does not document the intention to order a CGM nor does it document that the criteria are met. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Although this was approved by the Plan, the DME provider is still required to maintain supporting records on file. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) and supplies provided on April 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the inpatient hospital care provided January 29, 2021, to February 2, 2021.

You asked the Plan to waive the cost share for the inpatient hospital care. You say that you would like this cost share waived. The Plan denied your request. The Plan says the cost share has processed 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 $300 deductible for inpatient hospital care. 

You have been asked to pay a $300 deductible for the inpatient hospital care followed by a coinsurance of $821.71 ($8217.10a Medicare-allowed amount x 10% coinsurance). 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 cost share for the inpatient hospital care provided January 29, 2021, to February 2, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on April 17, 2021.

You asked the Plan to waive the copayment for the emergency room visit. You say that you do not feel you should be responsible for the copayment. You say they did not check your blood pressure or temperature. 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 $90 copayment per visit for Medicare-covered emergency room visits.

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 medical record shows you were evaluated and treated for right-sided hip pain during your emergency room visit.

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 April 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and preventive procedure provided on March 24, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation and preventive procedure. You say that the provider made appointments knowing you expected to have your bottom denture relined. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits.

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 problem focused limited oral evaluation and preventive procedure provided on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided to the enrollee on August 25, 2020.

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 does not have out-of-network benefits.

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 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 an office visit provided to the enrollee on August 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing.

You asked the Plan to pre-approve genetic testing. You say that this testing is medically necessary. The Plan denied your request. The Plan says this testing is not covered by Medicare for your condition.

The Plan must follow Medicare rules. Medicare rules state the genetic testing requested is only covered for pregnant women. You do not meet these criteria. Therefore, we decided that the Plan does not have to pre-approve genetic testing.
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 service is medically necessary. The Plan denied your request. The Plan says the services is not medically necessary.
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 enrollee's medical conditions are stable and they have no complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation 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 IRF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 5, 2020.

You asked the Plan to pay for the laboratory 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided on February 25, 2021.

You asked the Plan to waive the coinsurance for radiation therapy services. You say that you could have done surgery for free but was advised of radiation treatment. You say that you were never told there was 20% coinsurance. 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 20% coinsurance per visit for radiation therapy.

You have been asked to pay $63.65, which is 20% of the allowed amount for radiation therapy services. The allowed amount is $318.23 (20% x $318.23 = $63.65). Radiation therapy services fall 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 coinsurance for radiation therapy services provided on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on March 22, 2021.

You asked the Plan to pay for the re-cement or re-bond crown. You say that this service should be covered at 50%. The Plan denied your request. The Plan says this service is not covered. The Plan also says that the Platinum Dental Rider was not active on this date of 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, 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 re-cement or re-bond crown (D2920) provided on March 22, 2021.