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

We decided that the Plan does not have to waive the copayment for arthroplasty provided on December 2, 2020.
You asked the Plan to waive the copayment for arthroplasty. You say that you were told that you would only owe a $125 copayment. 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 $150 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $150 copayment for arthroplasty. Arthroplasty falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for arthroplasty provided on December 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of a spinal cord stimulator (63650).

You asked the Plan to pre-approve the implantation of a spinal cord stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for patients who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. Such screening must include a psychological evaluation. 

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 implantation of a spinal cord stimulator. Our reviewer says that the requirements for coverage for a spinal cord stimulator have not been met. Our physician reviewer found the records do not show that there has been a psychological screening test. 

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 implantation of a spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation of a spinal cord stimulator (63650).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient office visit (9923) sciatic nerve
injection (64445) injection, anesthetic agent, intercostal nerves, multiple, regional block (64421) anesthetic
agent(s), steroid, and or injection(s), the intercostal nerve and a single level (64420) provided January 7, 2021.

You asked the Plan to waive the copayment for the office visit. You say that you were told by the agent that
your provider was in network. You went to the office and they told you they do not accept the plan so here you
are having to pay a higher amount because your insurance agent lied. The Plan denied your request. The Plan
says the claim was processed, and the correct cost share was applied per the Evidence of Coverage.

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 45% for
surgical procedures performed by a physician/practitioner in a provider's office.

You have been asked to pay $159.51 for the office visit. 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 outpatient office visit (9923) sciatic nerve injection (64445) injection, anesthetic agent, intercostal nerves,
multiple, regional block (64421) anesthetic agent(s), steroid, and or injection(s), the intercostal nerve and a
single level (64420) provided January 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from January 6, 2020, to January 26, 2020.
You asked the Plan to waive the copayment for SNF care. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 each day for days 1 to 20, and a $156 copayment each day for days 21 to 100 of a covered stay during a benefit period for Skilled Nursing Facility (SNF) care. This SNF stay lasted 20 days, which were days 7 to 26 of the benefit period, resulting in a total copayment amount of $936. The enrollee has been asked to pay a $0 copayment each day for days 1 to 20, and a $156 copayment each day for days 21 to 100 of a covered stay during a benefit period for SNF care. SNF care 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 copayment for the SNF care provided from January 6, 2020, to January 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the assessment for hearing aid (V5010) and repair/modification of a hearing aid (V5014) provided November 25, 2020 and December 10, 2020.
You asked the Plan to pay for the hearing aid assessment and repair/modification. You say that you were told the hearing aid services would be covered. The Plan denied your request. The Plan says services to hearing aids are covered for one year. Since the services were provided more than a year after receiving the hearing aids, they are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids on per ear per year. The Plan contract does not state that hearing aid assessments and repair/modifications are covered under your supplemental benefits. Your signed Purchase Agreement & Delivery Receipt states that you have a one-year warranty for the purchased hearing aids. This includes one year of service at no charge (with the original provider). We looked at the file and the Plan's rules. You purchased hearing aids on August 28, 2019. Your purchase included one year of service free of charge. The assessment and repair/modifications were provided more than
a year after the purchase date. Therefore, we decided that the Plan does not have to pay for the assessment for hearing aid (V5010) and repair/modification of a hearing aid (V5014) provided November 25, 2020 and December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a partial upper denture (D5213), and a partial lower denture (D5214) provided on May 20, 2020.
You asked the Plan to pay for a partial upper denture, and a partial lower denture. You say that you thought the services at issue were covered. The Plan denied your request. The Plan says the services at issue are not covered benefits. You were not enrolled with the additional supplemental benefit on the 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 a partial upper denture (D5213), and a partial lower denture (D5214) provided on May 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ruxience for the enrollee.
You asked the Plan to pre-approve Ruxience. You say that this is medically necessary. The Plan denied your
request. The Plan says that the drug is not being prescribed for a medically accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Ruxience. Our reviewer says that
Ruxience is not medically reasonable and necessary for the enrollee. The enrollee has idiopathic
thrombocytopenic purpura. The noted diagnosis is not a Food and Drug Administration approved use or a
medically accepted indication of the requested formulation as defined by Medicare rules. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for Ruxience.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Ruxience have not been met. Therefore, we decided that the Plan does not have
to pre-approve Ruxience for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for an outpatient surgery
provided by a participating provider on November 17, 2020.
You asked the Plan to waive the deductible and copayment for an outpatient surgery. You say that you should
only owe $250 for each surgery. The Plan denied your request. The Plan says the correct charges have been
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 $1,000
deductible and a $250 copayment for outpatient surgery.
You have been asked to pay a $1,000 deductible and a $109.27 copayment, which is less than your copayment
amount of $250, for an outpatient surgery. The total amount you are being asked to pay is $1,109.27 ($1,000
deductible + $109.27 copayment = $1,109.27). An outpatient surgery falls within the outpatient surgery 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 deductible and copayment for an outpatient surgery provided
by a participating provider on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided on August 28,
2020, and August 29, 2020.

You asked the Plan to waive the copayments for specialist visits. You say that you did not receive the services
and feel that the charges are unethical. 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 $45
copayment for each specialist visit.

The medical records show that you received specialist services on August 28, 2020. Therefore, you are
responsible to pay the $45 copayment.

The medical records show that you received specialist services on August 29, 2020. Therefore, you are
responsible to pay the $45 copayment. The total amount you owe is: $90.

You have been asked to pay the total copayment amount of $90 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 for specialist visits provided on August 28, 2020, and August 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that you are appealing this denial. The Plan denied your request. The Plan says these items are not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the MRI provided on December 31, 2020.

You asked the Plan to waive the co-payment for the MRI. You say that you cannot afford the co-payment. 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
co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150
co-payment per visit for all other outpatient diagnostic and therapeutic services and supplies, such as MRAs,
MRIs, CT scans, PET scans, and hyperbaric oxygen therapy.

You have been asked to pay a $150 co-payment for the MRI. The MRI 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 MRI provided on December 31, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared light therapy (97026) therapeutic exercises (97110) hot/cold packs (97010) manual therapy techniques (97140) provided December 1, 2020 to December 23, 2020.

You asked the Plan to pay for the physical therapy services. You say that you feel the services should be covered because it is doing you some good. The heat, the stem and then the exercises are all helping you. The Plan denied your request. The Plan says there was no clinical documentation received from the enrollee or the provider to support medical necessity for the course of therapy.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. The plan had made many attempts to obtain medical records from the provider without success. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for infrared light therapy (97026) therapeutic exercises (97110) hot/cold packs (97010) manual therapy techniques (97140) provided December 1, 2020 to December 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an outpatient surgical procedure provided on December 10, 2020.

You asked the Plan to waive the co-payment for an outpatient surgical procedure. You say that you pay a premium and feel that you should not owe anything for the 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 co-payment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $150 co-payment for an outpatient surgical procedure. An outpatient surgical procedure falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for an outpatient surgical procedure provided on December 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 22, 2021 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 lab work provided on January 22, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 5, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on August 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the stress test (CPT code 78452) provided on December 18, 2020.

You asked the Plan to waive the copayment for the stress test. You say that the test performed was ineffective and had inaccurate results. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC 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).

Review of the file show that you received the stress test on December 18, 2020. You were asked to pay a $200 copayment for the stress test. Your 2020 EOC says that enrollees must pay a $200 copayment after the deductible is met for each advanced imaging service (e.g., MRI, CT and PET scans, nuclear medicine, and stress tests). 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 stress test (CPT code 78452) provided on December 18, 2020.
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 services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 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.