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

 We decided that the Plan does not have to pay for the dental services provided on September 3, 2021.  You asked the Plan to pay for the dental services. You say that since you've been going to this provider there is nothing that hasn't been covered. You say that your dentist in in-network and should be covered. The Plan denied your request. The Plan says payment cannot be made for services received from a provider that has opted out of Medicare.  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, dental services received from a provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on September 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessories.
You asked the Plan to pre-approve the requested services. You say that The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. A seat lift does not serve a purpose that is primarily medical in nature.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The file shows that an enhanced color display was requested. This item is a component of the approved expandable control system and is not separately reportable. Therefore, we decided that the Plan does not have to pre-approve wheelchair accessories.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that it is taking longer to recover than expected. The
Plan denied your request. The Plan says continued SNF care is not medically necessary because the enrollee
has reached the maximum potential and there is no indication of improvement in a reasonable predictable
amount of time.

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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely
and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date.
The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled
nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized
skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary
and reasonable treatment in a SNF beyond the last covered date. The enrollee does not require skilled nursing
or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical
matter the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility
setting beyond the last covered date.

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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the specialist office visit provided on January 26, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the provider did not do anything.  The Plan denied your request. The Plan says you have been asked to pay 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 $35 copayment per provider per day for each in-network Medicare-covered specialist office visit.   You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen for the evaluation and management of your right hip.  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 specialist office visit provided on January 26, 2021.   Your complaint that the appointment was a waste of time and money 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from June 28, 2021, to July 6, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that this bill was for services rendered in December 2020 and should have no cost-share. The Plan denied your request. The Plan says the bill in question is for inpatient care provided from June 28, 2021, to July 6, 2021. This claim was processed correctly, and your copayment was assessed in accordance with your contract. Inpatient care requires a $200 copayment for each of the first seven days of a hospital admission. The Plan also says they are reviewing your grievance as a separate case.
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 $200 copayment for each of the first eight days of an inpatient hospital stay.
You have been asked to pay a $1,400 copayment for the seven-day hospital stay ($200 x 7 = $1,400). 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 inpatient hospital admission and services provided from June 28, 2021, to July 6, 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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be more stable and should only require short-term additional acute care services such as additional weaning attempts that can be safely received at the current hospital for now. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam with photos (92250) provided on September 16,
2021.
You asked the Plan to pay for an eye exam with photos. You say that you were told by the provider that the
total amount owed was $0.00. The Plan denied your request. The Plan says the requested service is not covered
by your Plan.
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 contract does not cover this service.
We looked at the file and the Plan's rules. The services at issue are not covered benefits of Medicare or the
Plan. Based on this information, we decided that the Plan's rules for coverage of an eye exam with photos have
not been met. Therefore, we decided that the Plan does not have to pay for an eye exam with photos (92250)
provided on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for collection of venous blood by venipuncture (CPT code 36415) provided to the enrollee on September 9, 2021, by an out-of-network provider.

You asked the Plan to pay for the out-of-network service. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.

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 collection of venous blood by venipuncture (CPT code 36415) provided to the enrollee on September 9, 2021, by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custodial care services.

You asked the Plan to pre-approve the requested services. You say that you need assistance with day-to-day tasks. The Plan denied your request. The Plan says custodial care is not a covered benefit.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. We find that the services at issue in this case are considered custodial in nature. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve custodial care services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit provided on September 8,
2020.
You asked the Plan to waive the coinsurance for the office visit. You say that you are not responsible for the
amount of $25.90. The Plan denied your request. The Plan says you have been asked to pay the correct costsharing
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 out-of-network Medicare-covered primary care doctor visit, specialist visit and other
health care professional visit.
You have been asked to pay $25.90 which is 30% of the allowed amount for the office visit. The allowed
amount is $86.32. ($86.32 x 30% = $25.90). The office visit falls within the "Physician/Practitioner services,
including doctor's office 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 coinsurance for
the office visit provided on September 8, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy (45380)
provided on July 12, 2021.

You asked the Plan to waive the copayment for the colonoscopy. You say that this service was necessary and
should be covered by Medicare. You feel you are responsible for 20% of the copayment amount. The Plan
denied your request. The Plan says this service is covered, and your copayment was assessed in accordance
with your contract.

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 surgery services provided in an ambulatory surgical setting.

You have been asked to pay a $275 copayment for the colonoscopy. The colonoscopy in this case included a
biopsy and was billed with code 45380. This service is classified as a surgical procedure and was performed in
an ambulatory surgical center. 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 colonoscopy with
biopsy (45380) provided on July 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the screening mammography services (77063, 77067) provided on August 16, 2021.  You asked the Plan to pay for the screening mammography services. You say that this claim should be reprocessed based on the medical documentation. The Plan denied your request. The Plan says the claim has been billed with an invalid Place of Treatment.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We looked at the file and Medicare rules. In this case, these services were billed as being performed in an emergency room. Based on the documentation provided, they should have been billed as outpatient hospital radiology. Based on this information, we decided that Medicare rules for coverage of the screening mammography services have not been met. Therefore, we decided that the Plan does not have to pay for the screening mammography services (77063, 77067) provided on August 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is not documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
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 pre-approve inpatient hospital services. Our
reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The
patient has spinal stenosis. Lumbar laminectomy (elective, nonemergent) was requested to be completed as
inpatient admission. The enrollee has a medical history that is significant for hypertension, gastroesophageal
reflux disease, and glaucoma. In this case, the provided documentation does not reveal the patient being
unstable medically or at high risk for unexpected outcomes that might require a hospital stay. There is no
expectation at the time of this request that the patient would require hospital services that would likely cross 2
midnights for this elective typically ambulatory procedure. Our physician reviewer found that the enrollee's
condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically
necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH
services do not meet the requirements for approval.

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 the record indicates that the enrollee still has leukocytosis and requires ongoing
acute care services. The enrollee continues to receive acute care services, and these have not been denied. The
medical record does not indicate that the enrollee requires services that he is not currently receiving but that
would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested
service cannot be recommended.

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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network
(OON) provider on April 27, 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 office visit (99204) rendered by the out-of-network (OON) provider on April 27,
2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the psychotherapy, 45 minutes with patient (CPT) code 90834 provided on August 23, 2021.

You asked the Plan to waive the copayment for the service. You say that the visit was a five (5) minute medication check-up to see if it is still working and to send it to the pharmacy. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

You pay a $25 for each individual or group therapy visit for Medicare-covered outpatient mental health 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 the psychotherapy, 45 minutes with patient (CPT) code 90834 provided on August 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the alcohol and/or drug services (H0010) provided from July 17, 2020, to December 7, 2020.
You asked the Plan to pay for the alcohol and/or drug services. You say that these services were provided in good faith to the enrollee in accordance with their plan benefits. The Plan denied your request. The Plan says the treating provider is not in-network. The Plan also says that they confirmed with the facility that they do not accept Medicare assignment.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the alcohol and/or drug services (H0010) provided from July 17, 2020, to December 7, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for medication assisted treatment, methadone (CPT code G2067) provided from June 7, 2021, through September 13, 2021, by an in-network provider.
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claims were processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you received medication assisted treatment for fourteen (14) dates of service from June 7, 2021, through September 13, 2021.
You were asked to pay a $40 copayment per date of service for each in-network Medicare-covered opioid use disorder treatment 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 medication assisted treatment, methadone (CPT code G2067) provided from June 7, 2021, through September 13, 2021, by an in-network provider.