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

We decided that the Plan does not have to waive the copayment for an ER visit provided from November 24, 2019 to November 25, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you were admitted to the hospital and thought that you would not be responsible for the ER 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 $65 copayment for emergency care. The copayment is waived if you are admitted to the hospital within 24 hours with the same condition. The medical records show that you were admitted under observation after an ER visit from November 24, 2019 to November 25, 2019. Observation is not considered an inpatient admission. Therefore, you are responsible to pay the $65 copayment for the ER visit. You have been asked to pay a $65 copayment for an ER visit. An ER visit falls within the emergency 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 an ER visit provided from November 24, 2019 to November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living services provided on February 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for assisted living services. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 hav
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery provided from November 14, 2019 to November 15, 2019.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you cannot afford this payment. You say you only get a disability check and have many other bills to pay. 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 $325 copayment for Medicare-covered outpatient hospital services. You have been asked to pay a $325 copayment for the outpatient surgery. The outpatient surgery 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 the outpatient surgery provided from November 14, 2019 to November 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on August 10, 2019.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the dental services you received are not listed as 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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on August 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira 40mg/0.4ml pen.You asked the Plan to pre-approvethe Humira Pen. You say that Humira is medically necessary.The Plan denied your request. The Plan says coverage for this self-administered drug is not available under the Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveHumira 40mg/0.4ml pen.Benefits for the Humira Penmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam (92012) provided on October 7, 2019.
You asked the Plan to waive the copayment for the eye exam. You say that you thought that this was just a regular visit after surgery to make sure your vision was better before surgery not an eye exam. The Plan denied your request. The Plan says this 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 $15 copayment for each Medicare covered outpatient visit for services to diagnose and treat disease or condition of the eye. for Vision care. You have been asked to pay $15 copayment for the eye exam. The eye exam falls 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 eye exam (92012) provided on October 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Hyalgan/Supartz injection or waive the
copayment for the administration of the injection provided on September 18, 2019.
You asked the Plan to waive the coinsurance for the Hyalgan/Supartz injection and waive the copayment for
the administration of the injection. You say that you were not told about the copay and coinsurance. The Plan
denied your request. The Plan says that the claims processed 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 20%
coinsurance for Medicare Part B prescription drugs and a $15 copayment for Provider and Professional
Services in a specialist's office.
You have been asked to pay a 20% coinsurance for the Hyalgan/Supartz injection and a $15 copayment for the
administration of the injection. The Hyalgan/Supartz injection falls within the Medicare Part B prescription
drugs and the administration of the injection falls into the Provider and Professional Services in a specialist's
office 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 Hyalgan/Supartz injection
or waive the copayment for the administration of the injection provided on September 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee needs the requested level of care in order to get better.The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the services needed could be provided in another setting.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 the enrollee's ongoing care needs include respiratory support with BiPAP, intravenous antibiotics, surveillance laboratory studies, tube feedings, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available atthe LTACH, that are not available at the current health care setting being offered by the health plan.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 LTACHservices have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe methylprednisolone acetate injection provided on September 19, 2019.You asked the Plan to waive the coinsurance forthe methylprednisolone acetate injection. You say that you were unaware of the additional charges.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 for Medicare Part B prescription drugs.You have been asked to pay $2.40, which is 20% of the allowed amount for the methylprednisolone acetate injection. The allowed amount is $12.02 (20% x $12.02 = $2.40). The methylprednisolone acetate injection falls within the "Medicare Part B prescription drugs" 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 forthe methylprednisolone acetate injection provided on September 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe laboratory services, the EKG, and the chest x-ray provided from July 25, 2019 to October 3, 2019.You asked the Plan to waive the copayments forthe laboratory services, the EKG, and the chest x-ray. You say that the lab services, the EKG, and the chest x-rays were not covered.The Plandenied 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for laboratory services at an in-network outpatient hospital and a $100 copaymentfrom basic radiological services at an in-network outpatient hospital. The enrollee has been asked to pay a total of $207.31 for the laboratory services, the EKG, and the chest x-ray. The laboratory services, the EKG, and the chest x-ray fall within the "Outpatient diagnostic tests and therapeutic services and 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 copayments forthe laboratory services, the EKG, and thechest x-ray provided from July 25, 2019 to October 3, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forphysical therapy servicesprovidedon June 27, 2019.You asked the Plan to pay forthe physical therapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approvethe physical therapy services. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forphysical therapy services provided onJune 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown for tooth #19.
You asked the Plan to pre-approve the crown. You say that the crown that was initially placed has not been functional appliance due to poor fit, open margins and significant mesial overhang. You also say that the enrollee is in pain and has recurrent decay. The Plan denied your request. The Plan says this service exceeds the allowable amount.
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, crowns are limited to one procedure every five years. The record shows that the enrollee received a crown on tooth #19 on March 26, 2019 and the enrollee's crown benefit for tooth #19 is now exhausted. Therefore, we decided that the Plan does not have to pre-approve the crown for tooth #19.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.
You asked the Plan to pre-approve a grab bar. You say that the requested grab bars are medically necessary for the enrollee. You say that the enrollee suffers from frequent falls among other medical concerns. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LymphaPress and arm sleeve from an out-of-network provider.You asked the Plan to pre-approve the LymphaPress and arm sleeve from an out-of-network provider. You say that the out-of-network provider is the exclusive provider of the Lymphapress pneumatic compression pump. You say that the clinical documentation provided supports the medical necessity of using this device.The Plan denied your request. The Plan says there are in-network providers in the enrollee's service area that can supply a pneumatic compression pump and arm garment.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.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 LymphaPress and arm sleeve from an out-of-network provider. Our reviewer says that the criteria for coverage of out-of-network care have not been met. Our physician reviewer found there is nothing unique to this claimant's condition that requires an out-of-network provider for lymphedema care. The plan's in-network providers can adequately provide care for the enrollee's condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of out-of-network care have not been met.Therefore, we decided that the Plan does not have to pre-approve the LymphaPress and arm sleeve from an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health aide services provided to the enrollee from September 3, 2019 to September 14, 2019.You asked the Plan to pay for the services. You say that this is medically necessary.The Plan denied your request. The Plan says this is considered custodial care.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. Our MAXIMUS review consultant says that the services at issue in this case were not medically reasonable or necessary.Our doctor found that in this case, the documentation doesn't support that the enrollee requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The care rendered from 9/3/19 through 9/14/19 were custodial in nature and therefore not medically necessary at a skilled level of care.Therefore, we decided that the Plan does not have to pay forhome health aide services provided to the enrollee from September 3, 2019 to September 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutritional therapy (97802 and 97803).
You asked the Plan to pre-approve medical nutrition therapy services. You say that you are borderline diabetic and obese and need help to manage your health. The Plan denied your request. The Plan says there is no record that you have any of covered clinical indications such as diabetes, renal disease or are post kidney transplant.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutritional therapy (97802 and 97803).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on September 13, 2019.You asked the Plan to pay for the hearing aids. You say that this was never explained to you by anyone. The description of Benefit for hearing aids indicates you share to be any amount over $1000 so you are confused about the complete denial.The Plan denied your request. The Plan says enrollee's must receive their hearing services from an in-network provider.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 only when hearing services are received from a network hearing or hearing aid provider.We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on September 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin based composite, 4 or more surfaces, for a posterior tooth (D2394) provided on October 31, 2019.You asked the Plan to pay for the dental service. You say that you have a letter from your doctor saying the service is medically necessary. You also say that you need to have your teeth fixed before you can get your hip replacement surgery.The Plan denied your request. The Plan says the resin based composite 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 filling is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the resin based composite, 4 or more surfaces, for a posterior tooth (D2394) provided on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 1 power mobility device.
You asked the Plan to provide a Group 1 power mobility device. You say that the enrollee needs a power mobility device to go shopping and walk the dog. The Plan denied your request. The Plan says the record shows the enrollee is a functional ambulator indoors and outdoors.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that the enrollee does not have a mobility deficit that impairs their participation in MRADLs, and that their condition can be improved by a walker, cane or manual wheelchair. Also, the item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers PMDs for use only outside the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to provide a Group 1 power mobility device.
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 the referral. You say that the physician is the only provider than can treat your complex condition. The Plan denied your request. The Plan says this is not a covered benefit with 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 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.