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

 We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on July 21, 2021.  You asked the Plan to pay for the complete maxillary and mandibular dentures. You say that you did not receive dentures in the past and believe these dentures should be paid for. The Plan denied your request. The Plan says benefits for these services have been satisfied and the frequency limitations have been exceeded. The Plan also says that the provider for this date of service has submitted information showing that you were seen on November 28, 2018, December 12, 2018, February 6, 2019, and March 27, 2019 for in office adjustments after receiving your dentures, and the dentures were sent home with you after each visit.  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 are limited to one upper complete and/or one lower complete denture every five years. The record shows that you received a complete maxillary denture (D5110) and complete mandibular denture (D5120) on October 17, 2018 and your complete maxillary and mandibular denture benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received from an independent laboratory on May 17, 2021.

You asked the Plan to waive the copayment for the lab services. You say that you have never had to pay a copayment in the past for lab services. 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 $15 copayment for lab services provided by a freestanding laboratory. 

You have been asked to pay a $15 copayment for the lab services. Records show that you had these lab services at an independent lab facility, so the copayment was assessed. This means that you have been asked to pay the correct amount based on your contract with the Plan. This copayment applies regardless of what you may have paid in the past. 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 lab services you received from an independent laboratory on May 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve arthroplasty, interposition, intercarpal or carpometacarpal joints (CPT code 25447 X 2), for the enrollee.  You asked the Plan to pre-approve the services. You say that the enrollee has significant scapho-trapezium/trapezoid (STT) arthritis and moderate carpometacarpal (CMC) joint arthritis in the right hand that has not been completely pain free for over a year. You state the enrollee has had cortisone injections, worn a splint, tried nonsteroidal anti-inflammatory drugs (NSAIDS), prescription pain medication, activity modification, ice, and heat with no avail. You state that physical therapy is not an option as this would make the enrollee's symptoms worse and only cause more aggravation and harm than good. The Plan denied your request. The Plan says the enrollee does not meet the requirements for this procedure. The Plan states the requirements are the enrollee has one (1) or more of the following conditions: Rheumatoid arthritis, Posttraumatic arthritis or other advanced disease (e.g. avascular necrosis, severe arthritis), and/or Revision of failed joint replacement. The Plan states the submitted clinical information does not show the enrollee has met a requirement for this procedure.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted (non-severe) OA pathology (over other medical and/or surgical options.) There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for arthroplasty, interposition, intercarpal or carpometacarpal joints (CPT 25447 X 2) is not medically reasonable or necessary.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve arthroplasty, interposition, intercarpal or carpometacarpal joints (CPT code 25447 X 2), for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulatory infusion pump (E0781) provided on November 27, 2020.  You asked the Plan to pay for the durable medical equipment. You say that the claim has not been paid in full or under the terms of the contract for the service provided to the enrollee. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on November 15, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulatory infusion pump (E0781) provided on November 27, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ultrasound, retroperitoneal, real time with image documentation; complete (76770) provided July 21, 2021.  You asked the Plan to waive the copayment for the retroperitoneal ultrasound. You say that you were told everything would be covered by insurance. The Plan denied your request. The Plan says the copayment was 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 $125 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility.  You have been asked to pay $121.53 for the retroperitoneal ultrasound. The retroperitoneal ultrasound falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay less than or equal to 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 ultrasound, retroperitoneal, real time with image documentation; complete (76770) provided July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 25, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 office visit provided on June 25, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a core build-up (D2950) and a crown (D2740) provided by a participating provider on July 21, 2021.

You asked the Plan to pay for a core build-up and a crown. You say that you think this is ridiculous that the Plan will not pay for this. You say that all of the work done was medically necessary. The Plan denied your request. The Plan says the dental services that were provided are not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a core build-up (D2950) and a crown (D2740) provided by a participating provider on July 21, 2021.
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. 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 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 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 has a past medical history of hypertension, diabetes and morbid obesity and is living at home being treated as an outpatient for shoulder pain and a skin tear. Medical problems are stable. 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. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 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 acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tangential biopsy of skin (11102), office visit (99213), excision of a malignant lesion (11603), complex repair of the scalp, arms, and/or legs (13121) and the complex repair of the scalp, arms, and/or legs; each additional 5 cm or less (13122) rendered by the out-of-network (OON) provider on March 11, 2021 and March 31, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 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 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 tangential biopsy of skin (11102), office visit (99213), excision of a malignant lesion (11603), complex repair of the scalp, arms, and/or legs (13121) and the complex repair of the scalp, arms, and/or legs; each additional 5 cm or less (13122) rendered by the out-of-network (OON) provider on March 11, 2021 and March 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires continuation of care for complex medical needs that require ongoing acute care. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH.  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 that there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she 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 are not 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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ultrasound you had on July 13, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that the Annual Notice of Change says that there is a $0 copayment for outpatient diagnostic tests. You also stated in additional information that you sent to us that you have never received a copy of your Evidence of Coverage. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($110.61) is less than your copayment obligation, you are responsible for the full allowed 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 $125 copayment for radiological diagnostic services.   The provision of the Annual Notice of Change that you reference on Page 15 applies to laboratory tests only, not to diagnostic radiology services.  You have been asked to pay a $125 copayment for the ultrasound. The ultrasound falls within the radiological diagnostic 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 ultrasound you had on July 13, 2021.   Your complaint about never receiving a copy of your Evidence of Coverage is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the muscle and/or fascia debridement (11043) rendered by the out-of-network (OON) provider on July 13, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the muscle and/or fascia debridement (11043) rendered by the out-of-network (OON) provider on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation (92012) and the excision of an eyelid lesion (67840) rendered by the out-of-network (OON) provider on August 13, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 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 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 ophthalmological medical examination and evaluation (92012) and the excision of an eyelid lesion (67840) rendered by the out-of-network (OON) provider on August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) you had at an outpatient hospital clinic on March 16, 2021.  You asked the Plan to waive the copayment for the ECG. You say that you were in your doctor's office, not a hospital, so you should only be responsible for a $40 copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this service ($43.83) is less than your copayment obligation, you are responsible for the full allowed 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 $275 copayment for outpatient diagnostic tests in an outpatient hospital facility.   The facility where you received these services bills as an outpatient hospital facility.  As a result, the outpatient hospital copayments apply. You have been asked to pay a $275 copayment for the ECG. The ECG falls within the outpatient diagnostic tests in an outpatient hospital facility 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 electrocardiogram (ECG) you had at an outpatient hospital clinic on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the abatacept injection you received on June 9, 2021.  You asked the Plan to waive the coinsurance for the abatacept injection. You say that you don't understand why the cost is so different from the estimate you were given. The Plan denied your request. The Plan says you were charged this coinsurance 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 drugs.   You have been asked to pay 20% coinsurance for the abatacept injection. The abatacept injection falls within the Medicare Part B 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 for the abatacept injection you received on June 9, 2021.   Your complaint about the estimate amount provided to you is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.