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

We decided that the Plan does not have to pay forthe medical services provided on November 11, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that it is the facilitiesresponsibility to obtain proper authorization.The Plan denied your request. The Plan says there is no network deficiency for the services, and alternate network providers were found.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 services at issue in this appeal. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these OON services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on November 11, 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 cost share applied for the periapical x-ray (D0230) and the two additional bitewing x-rays (D0272) provided on December 17, 2019
You asked the Plan to waive the cost share applied for these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the cost share has been applied correctly to the services provided.
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. We looked at the case file and Medicare rules. You have been asked to pay a $16 cost share for these services. A periapical x-ray was processed at a 50% coinsurance of the $14 allowable charge, for a $7 remaining balance. Additionally, four bitewing x-rays were provided. Two bitewing x-rays are covered by the Plan at each routine dental visit. The provider's charge was $35, in which the Plan paid $26, the allowed amount for two x-rays, with a remaining balance of $9. Based on this information, we decided that the cost share has been applied correctly to the services provided. Therefore, we decided that the Plan does not have to waive the cost share applied for the periapical x-ray (D0230) and the two additional bitewing x-rays (D0272) provided on December 17, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on May 29, 2019 to October 18, 2019 by an out of network (OON) provider.You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON 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 psychotherapy services provided on May 29, 2019 to October 18, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe chiropractic services. You say that you would like reconsideration because these services are medically necessary to treat the member's neck and back pain.The Plan denied your request. The Plan says there are providers who work with the Plan who can provide this service.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 providerwith 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-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. You say that this physician is helping you with treatment for diabetes. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on December 3, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that you were told that the colonoscopy would be covered. You believe this colonoscopy should be considered preventive because of the polyps. 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 $300 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $300 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows you have had polyps in the past which makes this colonoscopy diagnostic in nature. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe colonoscopy provided on December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) and a porcelain crown (D2740) for tooth # 29.You asked the Plan to pre-approve the dental services. You say that the existing crown on this tooth has fallen out twice since March. You say that its condition is deteriorating. You also say that you need a new crown in order to chew food properly and so that the gum tissue is not exposed to infection or damage.The Plan denied your request. The Plan says core build up and a porcelain crown are not listed as 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 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) and a porcelain crown (D2740) for tooth # 29
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 your wife called 911 for an ambulance after you had a reaction from being stung by a bee. You stated that the ambulance came but did not treat you in any way besides taking your blood pressure. After the ambulance responders left, you say that your wife drove you to the hospital after your symptoms got worse. You say that you are now receiving a bill from the ambulance company. 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 September 2, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99203) provided on January 7, 2020.
You asked the Plan to pay for a chiropractic office visit. You say that this should be covered because subsequent services were covered. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for a chiropractic office visit (99203) provided on January 7, 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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 you presented to the acute hospital with a left intertrochanteric hip fracture after a fall. You were treated in hospital by orthopedics who performed a surgical repair on June 1, 2020 with no complications. You are weak and unsteady and are working with physical and occupational therapy. You are weight bearing as tolerated. You required contact guard assistance with waling 15 feet times two with fair endurance. You required contact guard assistance for transfers. You required minimal assistance with bed mobility. You are medically stable. The documentation does not support that the complexity of your nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require treatment in an intensive rehabilitation therapy program. Your care needs can be met at a lower level of care.
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.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance forHBO provided from January 30, 2020 to February 5, 2020.You asked the Plan to waive the coinsurance forHBO. You say that you have never been charged in the past and disagree with the charges.The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.The rules say a plan must discloseto its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan does not say in clear and accurate terms how much you should expect to pay for HBO. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20% coinsurance for therapeutic services. The Plan contract does not clearly say how much enrollees must pay for HBO. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information.Therefore, we decided that the Plan has to waive the coinsurance forHBO provided from January 30, 2020 to February 5, 2020.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's servicesprovided on December 18, 2019.You asked thePlan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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-approve the servicesat issue. We found no exception that would require the Plan to pay for theseservices. Therefore, we decided that the Plan does not have to pay for physician's services providedon December 18, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forEmergency Room Services provided January 7 and 8, 2020.You asked the Plan to waive the copayment forthe Emergency Room services. You say that the enrollee was admitted so the emergency room copayment should be waived.The Plan denied your request. The Plan says the record does not show any inpatient claims for these service dates. 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 a $120 copayment for Emergency Care. You have been asked to pay a $120 copayment for the Emergency Room services. The Emergency Room services fall within the Emergency Care benefit category. The record does not show an inpatient admission. 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 forEmergency Room Services provided January 7 and 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe radiology services (A9500, 78070, A9512) provided on January 31, 2020.You asked the Plan to pay forthe radiology services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available.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 forthe radiology services (A9500, 78070, A9512) provided on January 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's needs are not complex, and does not require an intensive team for care.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 physician reviewer found that the enrollee has a history of Parkinson's, and is post deep brain stimulation placement. She has good and bad days, and is mostly independent with activities of daily living. She is at supervised to minimal assist for transfers and ambulation. The complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial upper denture (D5211) provided on September 30, 2019.
You asked the Plan to pay for the dental item. You say that you received a pre-treatment estimate stating that the denture would be covered. You also say that you did not know about the 2 year clause until January 2020. The Plan denied your request. The Plan says there is no approved pre-treatment estimate on file. The Plan also says dentures are not covered when the initial installation of a bridge or denture to replace teeth missing prior to coverage.
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 and partial dentures are a covered service, they are not covered to replace teeth that were missing prior to the start of your dental coverage. Additionally, the record shows that the partial denture was not estimated to be paid. Therefore, we decided that the Plan does not have to pay for the partial upper denture (D5211) provided on September 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you were at a friend's house for dinner when you began to feel tired. You say that you passed out for a few minutes and when you awoke, you were told an ambulance was on its way. You stated that you felt fine however you allowed the responders to check your vitals and evaluate you. You say that all was well and the responders left. You stated that you were shocked to receive such a large bill for the services and asked the Plan to reconsider their denial.The Plan denied your request. The Plan says these services are nota 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 December 23, 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 forthe ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the laser vaporization of prostate provided on September 4, 2019.You asked the Plan to waive the coinsurance for the laser vaporization of prostate. You say that you feel that the outpatient surgery charges are unfair.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 30% coinsurance for each surgery service provided in an outpatient hospital facility. You received the laser vaporization of prostate provided on September 4, 2019. The total allowed amount is $4,708.78 and 30% of that is $1,412.63. You have been asked to pay the total coinsurance amount of $1,412.63 for the laser vaporization of prostate. The laser vaporization of prostate 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 coinsurance for the laser vaporization of prostate provided on September 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for retreatment of previous root canal therapy - molar (D3348) provided on February 3, 2020.
You asked the Plan to pay for the dental services. You say that the services are necessary. The Plan denied your request. The Plan says the service is not a covered benefit under 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, the requested items or services are not among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for retreatment of previous root canal therapy - molar (D3348) provided on February 3, 2020.