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

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on November 21, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that there should not have been a copayment for a follow-up to the biopsy. 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 $35 copayment per specialist visit. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.
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 a specialist office visit provided on November 21, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for services performed by a qualified physical therapist in a home health or hospice setting (G0151, G0156), and direct skilled nursing services of a registered nurse (RN) in a home health or hospice setting (G0299) provided on July 23, 2019 to September 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for services performed in a home health or hospice setting. You say that you are the only agency in the area that accepts the Plan. You have tried many times to be contracted. The Plan denied your request. The Plan says services from non-participating providers are not covered under the enrollee's plan. The services must be authorized by the Plan before the services are provided.
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 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 services performed by a qualified physical therapist in a home health or hospice setting (G0151, G0156), and direct skilled nursing services of a registered nurse (RN) in a home health or hospice setting (G0299) provided on July 23, 2019 to September 17, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic eye exam (92014) provided of November 7, 2019.
You asked the Plan to waive the copayment for the vision services. You say that this was a routine eye exam and you should not have a copay for this service. The Plan denied your request. The Plan says the claim was processed correctly and the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30 copayment per visit for exams to diagnose and treat diseases and conditions of the eye. for Vision care. You have been asked to pay $30 copayment for the vision services. The vision services fall within the Vision 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 the diagnostic eye exam (92014) provided of November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Verio test strips.
You asked the Plan to pre-approve the non-preferred brand of test strips. You say that the enrollee used One Touch Verio test strips. The Plan denied your request. The Plan says they will approve a 3 month transition supply with no refills but there is no medical reason documented that the enrollee is medically unable to use the preferred brand of test strips and meters.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. There is no documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve One Touch Verio test strips.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say thatMedicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy services on a daily basis. You do 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ten extractions, two removals of residual tooth roots, four jaw reconstructions, two alveoloplasties, and six anesthesia services provided on September 16, 2019.
You asked the Plan to pay for the extractions, removals of residual tooth roots, jaw reconstructions, alveoloplasties, and anesthesia services. You say that you felt your health was in jeopardy. You also say that some of the charges should be considered because you were informed that this provider was in-network. The Plan denied your request. The Plan says the records show that you do not have cancer and you have not had an injury to the jaw.
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 ten extractions, two removals of residual tooth roots, four jaw reconstructions, two alveoloplasties, and six anesthesia services provided on September 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tracheostoma revision (31613).
You asked the Plan to pre-approve a tracheostoma revision (31613). You say that the requested tracheostoma revision is medically necessary. The Plan denied your request. The Plan says the requested tracheostoma revision is 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 pre-approve a tracheostoma revision (31613). Our reviewer says that the requested tracheostoma revision is not medically necessary. Our physician reviewer found the enrollee is diagnosed with an airway obstruction. The enrollee has a trach stoma and needs a revision. Records do not provide details, beyond a diagnosis of "airway obstruction". The information provided does not justify the need for a tracheostomy revision. There is no documentation of airway obstruction or related symptoms. The tracheostomy revision is considered not medically necessary at this time. 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 tracheostoma revision (31613) have not been met. Therefore, we decided that the Plan does not have to pre-approve a tracheostoma revision (31613).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you had suffered from some smoke inhalation from a nearby fire and that is when the Fire Marshal requested that local firemen check on civilians. You say that you do not believe you should be liable for the bill. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 29, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Nitro rolling walker.
You asked the Plan to pre-approve a replacement walker. You say that you need this specific model inside and outside your home because it is safe and strong. The Plan denied your request. The Plan says you were provided a walker on December 30, 2016 that still meets your needs.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have walker with seat. Your walker with seat serves the same purpose as the replacement walker at issue. Medicare will cover a replacement if your medical condition changes such that the current equipment no longer meets your medical needs. The medical record does not show medical necessity for a new walker. Therefore, we decided that the Plan does not have to pre-approve a Nitro rolling walker.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from September 28, 2019 through October 4, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were admitted before and never had to pay. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 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 shows that you were admitted on September 28, 2019 and discharged on October 4, 2019. You were asked to pay a $350 copayment per day from September 28, 2019 through October 2, 2019, days 1-5 of your inpatient stay. There were no copayment charges from October 3, 2019, day 6 of your inpatient hospital care until your day of discharge October 4, 2019. Per your contract there is a $350 copayment per day required for days 1-5. 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 inpatient hospital care from September 28, 2019 through October 4, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ED visit and CT scan provided on August 28, 2019 and September 17, 2019.You asked the Plan to waive the copayment forthe ED visit and CT scan. You submitted your bill for review.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 $90 copayment for emergency services in an emergency room and a $250 copayment for advanced imaging services at an in-network outpatient hospital. You have been asked to pay a $90 copayment for the ED visit. You have also been asked to pay $111.42, which is less than the standard $250 copayment for the CT scan. The total amount you owe is $201.42 ($90 + $111.42 = $201.42). The ED visit falls within the "Emergency care" benefit category. The CT scan 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 ED visit and CT scan provided on August 28, 2019 and September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the vision services. You say that you were unaware that you were not credentialed and are now working on the credentialing process. The Plan denied your request. The Plan says services must be provided according to the Medicare coverage guidelines established by the Medicare program.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that vision services rendered by out-of-network providers are not covered. The requested provider in this case is not a network provider with the Plan. 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 the medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebrand specific speech generating device Tobii I12. You asked the Plan to pre-approveTobiiI12 device. You say that the enrollee depends on family members to assist in the movement of the wheelchair which has led to minor accidents. The quality of life of the enrollee will be better with the Tobii I12 equipment.The Plan denied your request.The Plan says the plan had already approved and paid for a speech generating device on 9/23/2019.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that the enrollee has GripPad 12 Communication Device coded as E2510, E2512 and E2599. The GripPad 12 Communication Device serves the same purpose asthe Tobii I12 device.Therefore, we decided that the Plan does not have to pre-approvebrand specific speech generating device Tobii I12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown (D2954), the periapical x-ray (D0220), and the amalgam (D2140) provided on January 10, 2019 by the out of network provider.
You asked the Plan to pay for the prefabricated post and core in addition to a crown. You say that it never crossed your mind that the provider may be out of network. You also say that you should be granted a one-time exception. You also say that you are very dissatisfied with the Plan's dental coverage. The Plan denied your request. The Plan says the prefabricated post and core in addition to a crown 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, the dental service you received is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown (D2954), the periapical x-ray (D0220), and the amalgam (D2140) provided on January 10, 2019 by the out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a colonoscopy and specialist services provided on November 11, 2020.
You asked the Plan to waive the copayments for a colonoscopy and specialist services. You say that this was a colonoscopy screening and you disagree with the charges. 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 $400 copayment for outpatient hospital surgery services. Your contract with the Plan also clearly says that you must pay a $50 copayment for visits with a specialist. Your appeal states that polyps were removed during a colonoscopy screening. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $400 copayment. You received specialist services on January 11, 2020. Therefore, you are responsible to pay the $50 copayment. The total amount you owe is: $450.
You have been asked to pay the total copayment amount of $450 for a colonoscopy and specialist services. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. Specialist services 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 a colonoscopy and specialist services provided on November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on September 10, 2019.
You asked the Plan to pay for the dental service. You say that you received a reimbursement check for your dental visit on September 20, 2019. You say that 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 pay for the periodontal maintenance (D4910) provided on September 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete mandibular denture. You say that you would like a replacement denture because you lost your bottom denture. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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, complete mandibular dentures (D5120) are limited to one procedure every five plan years. The record shows that you received a complete mandibular denture on March 13, 2019 and your complete mandibular denture benefit is now exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea low dose computed tomography (LDCT) scan for lung cancer screening (G0297).You asked the Plan to pre-approvea LDCT scan. You say that you need this test due to your family history.The Plan denied your request. The Plan says that the documentation does not show that you have the required pack-year history and have smoked within the past 15 years.The Plan follows Medicare rules. Medicare rules say that LDCT scans are covered when all of the above-listed criteria are met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve a LDCT scan. Our reviewer says that the criteria for coverage of a LDCT scan have been met. Our physician reviewer found your age, 40 pack-year smoking history, and quitting 15 years ago fall within the guidelines for screening with LDCT. You have had a previous exam as required by the NCD rules. The requested LDCT is considered medically necessary for you at this time.
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 LDCT scan have been met.Therefore, we decided that the Plan has to pre-approvea low dose computed tomography (LDCT) scan for lung cancer screening (G0297).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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) and the crown (D2740) provided on September 3, 2019.
You asked the Plan to pay for the dental services. You say that you had a cracked tooth. You say that you found a provider on the Plan website. You say that you were advised the Plan would pay for some of the services. You also say that the services you received were an emergency. The Plan denied your request. The Plan says the core build up and the crown are not covered services.
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 core build up and crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) and the crown (D2740) provided on September 3, 2019.