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

We decided that the Plan does not have to waive the coinsurance for Part B drugs (J1097) provided on August 18, 2021, and October 13, 2021.
You asked the Plan to waive the coinsurance for Part B drugs. You say that you could not have known that you needed more pain medication. The Plan denied your request. The Plan says the coinsurance applied was 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 a 20% coinsurance for Part B drugs obtained in an in-network provider's office or outpatient setting. You have been asked to pay $80.80 for Part B drugs provided on August 18, 2021, which is 20% of the allowed amount ($404.00 allowed amount x 20% coinsurance = $80.80). You have also been asked to pay $82.26 for Part B drugs provided on October 13, 2021, which is 20% of the allowed amount ($411.28 allowed amount x 20% coinsurance = $82.26). Your total coinsurance responsibility is $163.06 ($80.80 + $82.26).
Part B drugs fall 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 for Part B drugs (J1097) provided on August 18, 2021, and October 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Botulinum Toxin Type A, per unit (J0585) provided on October 4, 2021.  You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the item provided.  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 non-chemotherapy prescription drugs.   You have been asked to pay $634.44 (Plan allowed amount of $3,172.20 x 20% coinsurance) for the Medicare Part B drug provided.  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 Botulinum Toxin Type A, per unit (J0585) provided on October 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement services provided on August 11, 2021.
You asked the Plan to waive the copayment for the wound debridement. You say that the procedure was part of another visit and you feel that you should only have a specialist copayment. 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 $360
copayment for surgery or other services provided to you at an outpatient hospital. You have been asked to pay $343.31, which is less than the $360 copayment for the wound debridement. The wound debridement is considered a surgical procedure and 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 wound debridement services provided on August 11, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided from April 15, 2021, to April 16, 2021.  You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because you were admitted to the hospital. 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 $100 copayment for emergency care.   The record shows that you were admitted under observation after receiving emergency care on April 15, 2021, to April 16, 2021. Observation care is not considered an inpatient admission. Therefore, you are responsible to pay the $100 copayment.   You have been asked to pay a $100 copayment for emergency care. Emergency care 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 emergency care provided from April 15, 2021, to April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telephone evaluation and management service (99443) provided on September 23, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $40 copayment for each covered visit or consultation in an outpatient location with a specialist.
Enrollees pay the cost-sharing that applies to primary care services or specialist physician services for
Medicare-covered telehealth services received from your primary care physician or a specialist respectively.
You have been asked to pay a $40 copayment for telehealth specialist visit provided. 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 telephone evaluation and management service (99443) provided on
September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on October 4, 2021.
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says you have exhausted
your eyewear benefit.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services every 2 calendar years.
We looked at the file and the Plan's rules. The file shows that you used the eyewear benefit on May 28, 2020.
Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met.
Therefore, we decided that the Plan does not have to pay for eyeglasses provided on October 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on September 16, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you believe the lab should be responsible for this copayment. You said that you went to get lab work done and the lab had to redraw blood and poked you many times. You said that this caused you to sweat and pass out. 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 $325 copayment for ambulance services. 

You have been asked to pay a $325 copayment for the ambulance services. This copayment applies regardless
of the reason for the ambulance services. 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 ambulance services you received on September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and panoramic imaging (D0330) provided by a participating provider on September 27, 2021.  You asked the Plan to pay for a limited oral evaluation and panoramic imaging. You say that you needed these services done. The Plan denied your request. The Plan says the benefit limit for the dental services provided has already been exhausted.  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. The Plan covers a limited oral evaluation once every year and panoramic imaging once every three years.   We looked at the file and Medicare rules. Evidence was provided that show D0140 and D0330 was provided on September 2, 2021. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation and panoramic imaging have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and panoramic imaging (D0330) provided by a participating provider on September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and inhalation of nitrous oxide (D9230) provided on October 13, 2021.  

You asked the Plan to pay for the dental services. You say that these services were performed by an in-network provider, and you received conflicting information regarding your payment. The Plan denied your request. The Plan says these services are not covered by your dental 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 the guided tissue regeneration (D4266) and inhalation of nitrous oxide (D9230) provided on October 13, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air mileage (A0436) provided on March 1, 2021.
You asked the Plan to pay for the rotary wing air transport and mileage. You say that the enrollee was not under hospice care during this date of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air mileage (A0436) provided on March 1, 2021.
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 want to go to an inpatient rehabilitation instead of a skilled nursing facility. The Plan denied your request. The Plan says the enrollee does not meet the criteria for IRF level of care. Care can be provided safely at a less intensive setting of care such as a skilled nursing facility.  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 enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee 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 enrollee 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: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that please consider you for more days because you are still unsteady walking because of your amputated toes and you are not comfortable going home alone yet. The Plan denied your request. The Plan says the continuation of SNF level of coverage is not medically necessary.  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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an X-ray provided on October 13, 2021.  You asked the Plan to waive the coinsurance for an X-ray. You say that you cannot afford the charges. 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 $0 copayment or 20% coinsurance for X-rays.  You received an X-ray on October 13, 2021. The record shows that you are not fully covered by Medicaid. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $77.54 and 20% of that is $15.51.   You have been asked to pay the total coinsurance amount of $15.51 for an X-ray. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an X-ray provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on September 1, 2021.
You asked the Plan to pay for the dental services. You say that you were not aware that the procedure needed
to be pre-approved. You also say that you would like to be reimbursed because the oral surgeon does not take
Medicare as payment. The Plan denied your request. The Plan says these services were rendered by a nonparticipating
provider. The Plan also says that there is no referring provider on this claim.
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 responsible for 100% of the
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay
for the dental services provided on September 1, 2021.
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 enrollee lives independently in a a senior apartment and wishes to continue living there. The Plan denied your request. The Plan says the enrollee does not meet the criteria for IRF services. Care can be safely received in alternative care such as in a skilled nursing facility, home with home healthcare or home with outpatient therapy.
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 enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee 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 enrollee 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on July 20, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network medical services provided to the enrollee on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (80307, G0480) provided on July 22, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the referring provider involved in these services is a non-participating provider with the Plan and the rendering provider is a non-participating provider. The Plan also says that they did not authorize any services for this 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 drug testing (80307, G0480) provided on July 22, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the specimen handling rendered on August 23, 2021.  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 services are not separately payable.  The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.  We looked at the file and Medicare rules. Billed procedure code 99000 has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the specimen handling rendered on August 23, 2021.