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

We decided that the Plan does not have to pay forthe established patient assisted living visit (99334) provided, by an out of network (OON) provider.You asked the Plan to pay forthe established patient assisted living visit. You say that the services provided were medically necessary.The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied.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 foundno exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe established patient assisted living visit (99334) provided, by an out of network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided on May 28, 2020.
You asked the Plan to waive the copayment for an outpatient hospital facility visit. You say that you should only owe a $40 specialist 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 hospital observation. You have been asked to pay the allowed amount of $140.45, which is less than the $150 copayment for an outpatient hospital facility visit. An outpatient hospital facility visit falls within the outpatient hospital observation benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided on May 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the broken upper complete denture repair (D5512).
You asked the Plan to pre-approve the broken upper complete denture repair (D5512). You say that the base is thinner than it should be and broke once already. You say that you haven't mishandled or dropped the denture, it cracked under normal usage. The Plan denied your request. The Plan says the 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, you also have a maximum benefit of one broken denture repair per denture every plan year. The Plan paid to repair the broken upper complete denture provided on July 8, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the broken upper complete denture repair (D5512).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forskilled nursing facility (SNF) services you receive.
You asked the Plan to waive the copayment forthe SNF services. You say that you were not aware of the additional cost for staying over 20 days.The Plan denied your request. The Plan says you were charged this copayment 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 $0 copayment for days 1-20 and a $178 copayment per day for days 21-100 for skilled nursing facility care. Records show that you were in the SNF, which is a total of 28 days.  You were not charged a copayment for the first 20 days. You have been asked to pay a copayment of $178 per day for the remaining 8 days, which is a total of $1424. This is clearly laid out in your contract. 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 forskilled nursing facility (SNF) services you received.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF care from November 17, 2020, forward.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 above. 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 complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for falls and confusion. Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 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 IRF care from November 17, 2020, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the patient lift.
You asked the Plan to pre-approve the patient lift. You say that you would like reconsideration because the lift is medically necessary. The Plan denied your request. The Plan says this provider does not participate in Medicare.
The Plan must follow Medicare rules. Medicare rules say that accredited DMEPOS suppliers means suppliers that have been accredited by a recognized independent accreditation organization approved by CMS in accordance with requirements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the patient lift have not been met. Specifically, the requested provider does not participate in Medicare. Therefore, we decided that the Plan does not have to pre-approve the patient lift.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided by a participating provider on March 16, 2020.You asked the Plan to waive the copayment for an eye exam. You say that you have eye coverage at 80%. You say that this should not be filed as a specialist visit. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharinginformation (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for vision care/eye exam. You have been asked to pay $44.27 which is less than your copayment amount of $50 for an eye exam. An eye exam falls within the vision care/eye exam benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an eye exam provided by a participating provider on March 16, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments foremergency care and an inpatient hospital stay from June 25, 2020, to June 27, 2020.You asked the Plan to waive the copayments foremergency care and an inpatient hospital stay. You say that the enrollee was not admitted to the hospital for over 24 hours and you feel that they should only owe a $250 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment for emergency care. The enrollee's contract with the Plan also clearly says that enrollee's must pay a $250 copayment for days 1-6 for inpatient hospital care.The enrollee received emergency care onJune 25, 2020. Therefore, theyare responsible to pay the $90 copayment. The enrollee received an inpatient hospital care from June 25, 2020, to June 27, 2020. Therefore, theyare responsible to pay a $250 copayment for days 1-2 (June 25, 2020, to June 26, 2020). $250 (copayment) x 2 (inpatient days)= $500. The total amount the enrollee owesis: $90 + $500 = $590. he enrollee has been asked to pay the total copayment amount of $590 for emergency care and an inpatient hospital stay. Emergency care falls within the emergency care benefit category. An inpatient hospital stayfalls within theinpatient hospital 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 thePlan does not have to waive the copayments foremergency care and an inpatient hospital stay from June 25, 2020, to June 27, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontal scaling and root planing, 1 to 3 teeth per quadrant, (D4342). You asked the Plan to pre-approve the dental service. You say that the service is necessary.The Plan denied you rrequest. The Plan says periodontal scaling and root planing for 1 to 3 teeth per quadrant is not listed as 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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve the periodontal scaling and root planing, 1 to 3 teeth per quadrant, (D4342).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214), radiologic examination (X-Ray) of foot (73620 and 73630) and a walking boot (L4361) provided on July 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit, X-Ray's and walking boot. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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 the office visit (99214), radiologic examination (X-Ray) of foot (73620 and 73630) and a walking boot (L4361) provided on July 5, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 18.
You asked the Plan to pre-approve the dental service. You say that there was insufficient structure once decay and old, broken restoration was removed. You say that core build up and full coverage restoration is necessary to restore tooth # 18 to optimum strength and function. You also say that core build up is needed for the retention of the crown. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan also says if a service is not listed then it is not covered.
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 pre-approve core build up (D2950) for tooth # 18.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation provided on July 13, 2020.You asked the Plan to pay forthe comprehensive oral evaluation. You say that you only wanted your teeth cleaned you did not ask for an exam. You say that you should have been informed of the charges for a new patient.The Plan denied your request. The Plan says the service exceeds the frequency limitation in the 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, you also have a maximum benefit of one comprehensive oral evaluation every three plan years. The Plan paid for a comprehensive oral evaluation provided on March 15, 2018, which exhausted your benefit.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation provided on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that you are frustrated with shortness of breath since June of 2020. The Plan denied your request. The Plan says the services are available from network providers.
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 referral to an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe gastric emptying study you had at an outpatient hospital facility.You asked the Plan to waive the copayment forthe gastric emptying study. You say that you do not have the money for this service and you were told that this would be covered.The Plan denied your request. 

The Plan says you were charged this copayment 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 $300 copayment for advanced imaging and nuclear medicine services. You have been asked to pay a $300 copayment for the gastric emptying study. The gastric emptying study falls within the advanced imaging and nuclear medicine services benefit category. This means that you have been asked to pay the correct amountbased 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 gastric emptying study you had at an outpatient hospital facility
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe unspecified adjunctive procedures (D9999 x 2) provided on June 30, 2020.You asked the Plan to reimburse you forthe dental services. You say that you were never advised that this dentist was out of network. You say that the provider's office did not check your insurance until afteryou received the services. You also say that you still need your broken tooth fixed.The Plan denied your request. The Plan says adjunctive dental service is not listed as a covered service. The Plan says that the provider in this case is not a network provider. The Plan also says that services that you receive out of network are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coveragerules 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 when you receive them out of network.Therefore, we decided that the Plan does not have to reimburse you forthe unspecified adjunctive procedures (D9999 x 2) provided on June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forwheelchair joystick mount (E1028) and the wheelchair repair (K0739) provided on July 17, 2020.You asked the Plan to waive the coinsurance forwheelchair joystick mount and repair. You say that you do not believe the member should be held responsible for the cost share.The Plan denied your request.The Plan says the cost share 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 an 18% coinsurance for Durable medical equipment (DME) and related supplies. The enrollee has been asked to pay an 18% coinsurance for wheelchair joystick mount and repair. This service falls within the Durable medical equipment (DME) and related supplies 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 coinsurance forwheelchair joystick mount (E1028) and the wheelchair repair (K0739) provided on July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on June 18, 2020.You asked the Planto waive the copayment for a specialist office visit. You say that you do not think you should be charged for this. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees inclear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for physician/practitioner services/specialist. You have been asked to pay a$15 copayment which is less than your copayment amount of $35 for a specialist office visit. a specialist office visit falls within the physician/practitioner services/specialist 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 a specialist office visit provided by a participating provider on June 18, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health care provided .You asked the Plan to pay for these services. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says the provider is not a Medicare eligible provider.

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. The services at issue in this appeal were rendered by a provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay foroutpatient mental health care provided.