Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on April 5,
2021.

You asked the Plan to pay for the comprehensive oral exam. You say that you would like the Plan to reconsider
their denial of payment. The Plan denied your request. The Plan says a comprehensive oral exam is only
covered once every 36 months. The Plan says you last received this type of exam on August 26, 2020, which is
less than 36 months ago.

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, comprehensive oral exams are only
covered once every 36 months. The file shows that you last received this type of exam on August 26, 2020,
which is less than 36 months ago. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on April 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the shoulder surgery provided on March 19, 2021.

You asked the Plan to waive the copayment for the shoulder surgery. You say that you would like to appeal your copay. The Plan denied your request. The Plan says the claim processed appropriately.

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 $175 copayment for ambulatory surgical center visits. 

You have been asked to pay a $175 copayment for the shoulder surgery. The shoulder surgery falls within the ambulatory surgical center visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the shoulder surgery provided on March 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the lenses provided on May 3, 2021.

You asked the Plan to pay more for the lenses. You say that you enclosed a letter of referral for the services. You say that you are appealing the decision to deny payment. The Plan denied your request. The Plan says the Plan has paid the maximum benefit for the routine vision hardware. Any charges above the benefit maximum of $220 is member responsibility.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $220 per calendar year for routine vision hardware. 

We looked at the file and the Plan's rules. The Plan paid $220 toward the lenses provided on May 3, 2021. Based on this information, we decided that the Plan's rules for coverage of the lenses have not been met. Therefore, we decided that the Plan does not have to pay more for the lenses provided on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the out-of-network neurology services provided on December 9, 2020 by an out-of-network provider.

You asked the Plan to pay for the nerve conduction studies. You say that the procedure was necessary and covered, Medicare paid their portion. The Plan denied your request. The Plan says there are in-network providers within five miles of your zip code, so you were charged the cost share correctly.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. The out-of-network services were covered by Original Medicare and you are responsible for the cost-sharing amounts. Therefore, we decided that the Plan does not have to pay for the out-of-network neurology services provided on December 9, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a surgical eye injection procedure provided on February 18, 2021.

You asked the Plan to waive the copayment for outpatient surgery. You say that you should only have a copayment of $40. The Plan denied your request. The Plan says this was only an eye exam and the copayment amount you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $350 copayment for outpatient surgery at an outpatient hospital. 

You have been asked to pay $350 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Outpatient Hospital 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 a surgical eye injection procedure provided on February 18, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation hospital services (G0378, 93005, Q9967,
J1650) provided on November 30, 2020 to December 4, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the observation services. You say that the treatment and services provided by
your facility for this enrollee's medical care were medically necessary. The Plan denied your request. The Plan
says enrollee's must receive their medical services from an in-network provider with the exception being
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization
before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the observation hospital services (G0378, 93005,
Q9967, J1650) provided on November 30, 2020 to December 4, 2020 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from December 1, 2020 to December 28, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claims were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with a valid HIPPS code. We looked at the file and Medicare rules. The file shows that the claims were not billed with a valid HIPPS code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from December 1, 2020 to December 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life
support, emergency transport, level 1 (A0427) provided March 15, 2021, and April 9, 2021.

You asked the Plan to waive the copayment for the ambulance transports. You say that you only had to take
additional ambulance transports because the hospital wasn't able to help you The Plan denied your request. The
Plan says the copayments were 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 $300
copayment for Medicare-covered ambulance transport (one-way).

You have been asked to pay a total of $600 ($300 copayment x 2 transports = $600) for the ambulance
transports. This service falls within the Ambulance services 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 ambulance service, advanced life support, emergency transport, level 1 (A0427) provided March 15, 2021, and April 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for occupational therapy provided on March 5,
2021.

You asked the Plan to waive the copayment for occupational therapy. You say that you were charged $40 for
therapy and thought that would be included in the outpatient surgery charge. You say that you were not charged
for therapy with previous surgeries and the $40 should be reconsidered. The Plan denied your request. The Plan
says the copayment 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 $40 per
day for Medicare-covered occupational therapy services from an in-network provider.

You have been asked to pay a $40 copayment for occupational therapy. Occupational therapy falls within the
"Outpatient rehabilitation services" benefit category. The occupational therapy is considered a separate service.
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 occupational therapy provided on March 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 2, 2020, to June 3, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically necessary and provided at the appropriate level of care. The Plan denied your request. The Plan says the denial of payment for this inpatient stay is correct, because inpatient criteria were not met and this stay could have been provided at the outpatient observation level.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span at least 2 midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 2, 2020, to June 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found your medical conditions are stable you have no complex nursing or rehabilitation needs. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation 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. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 11, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost share for the drug administration. We decided that the Plan does not have to reduce the cost share for the Part B drug.

You asked the Plan to reduce the cost share for the Part B drug and its administration. You say that you are only able to pay a $35 copayment. You say you the specialist's office was closed due to a snowstorm and you had to go to the hospital. The Plan says that you have been asked to pay the correct cost-sharing amount.

We decided that the Plan has to reduce the cost share for the drug administration.

The record shows the cost share listed will apply for the administration of drugs in all places of treatment. 

The Plan says that you must pay $59.77 for the drug administration. Based on the plan contract, however, you cannot be asked to pay more than an $11.95 coinsurance amount for the drug administration. ($59.77 x 20% = $11.95). Therefore, we decided that the Plan has to reduce the cost share for the drug administration from $59.77 to $11.95.

We also decided that the Plan does not have to reduce the cost share for the Part B drug.

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% of the allowed amount for the Part B drug and its administration. The allowed amount of the Part B drug is $882.06. ($882.06 x 20% = $176.41). Therefore, we decided that the Plan does not have to reduce the cost share for the Part B drug.

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 the nuclear medicine study of bone (78306, A9503) provided on March 26, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the nuclear medicine study of bone. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the nuclear medicine study of bone (78306, A9503) provided on March 26, 2021, by an out-of-network (OON) provider.
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 need IRF care to continue to regain strength before you return home. The Plan denied your request. The Plan says the rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that you were admitted for syncope and dehydration. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Although you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve SNF care. You say that skilled nursing care is necessary for the enrollee to have physical, occupational and speech therapy. The Plan denied your request. The Plan says that that criteria for SNF care is not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care is medically reasonable and necessary for the enrollee. The enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee appears to be functioning below her prior baseline. It is not clear that the enrollee has reached a new baseline. A trial of daily skilled services is reasonable until documentation shows a plateau in function has been reached. Our physician reviewer found that the enrollee's condition meets Medicare criteria for SNF services. 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care for the enrollee.
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 the chiropractic services provided on March 2, 2021, to March 3, 2021, by an OON provider.
You asked the Plan to pay for the OON services. You say that you did not know he was not part of the plan. The Plan denied your request. The Plan says services were with an out-of-network provider without an authorization on file.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the chiropractic services at issue in this appeal. The Plan did not pre-approve the
services at issue. 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 for the chiropractic services provided on March 2, 2021, to March 3,
2021, by an OON provider.