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

We decided that the Plan does not have to pay for SNF services provided from April 21, 2021, through
May 15, 2021.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says SNF services provided from April 21, 2021, through May 15, 2021 are denied due to no daily skilled needs.

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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy at a non-skilled level in the SNF. By the dates in question, the enrollee was at a standby assist to contact guard assist level with functional mobility including gait to short distances. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee 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 pay for SNF services provided from April 21, 2021, through May 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a rigid helmet.
You asked the Plan to pre-approve a rigid helmet. You say that this is medically necessary to protect your head. The Plan denied your request. The Plan says that items that serve a precautionary or safety purpose, such as a helmet used for protective purposes, are not covered in accord with Medicare guidelines.
The Plan must follow Medicare rules. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Equipment that is presumptively non-medical in nature and used primarily and customarily for a non-medical purpose, even though the item may have some remote medically-related use, is not considered durable medical equipment. Therefore, we decided that the Plan does not have to pre-approve a rigid helmet.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Botox is covered when specific criteria are met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has gastroparesis. She does not have a diagnosis for which the use of Botox is covered by the Medicare criteria. There is no documentation to support that the Botox is reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair with slide.

You asked the Plan to pre-approve a shower chair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not primarily medical in nature and is not payable by Medicare.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair with slide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency dental services rendered on March 6, 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 covered.
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. The services are not covered by the enrollee's medical benefit because they were services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Therefore, we decided that the Plan does not have to pay for the emergency dental services rendered on March 6, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on
May 20, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you went to an urgent care center but
they referred you to the ER because they didn't have the lab test you needed. You stated that you think this
should be adjusted because it was not an emergency visit. 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 $110
copayment for visits to the emergency room. You have been asked to pay a $110 copayment for the ER visit. This copayment applies regardless of the
reason for the ER visit. 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 emergency room (ER) visit
you had on May 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services you received from August 26, 2020, to September 11, 2020.
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you were told that days 1-20 at the facility would have a $0 copayment. 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 $245 copayment per day for days 1-6, and a $0 copayment for additional days, for inpatient hospital care, including inpatient rehabilitation.
You have been asked to pay a $245 copayment per day for days 1-6 for the inpatient rehabilitation services. It appears as though you may be referencing the cost sharing for skilled nursing facility (SNF) in your appeal letter. The facility that provided these services is not a SNF, but an inpatient rehabilitation facility. 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 inpatient rehabilitation services you received from August 26, 2020, to September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the subcutaneous tissue debridement
(11042 x 3), open wound debridement (97597), and the removal of devitalized tissue from wound(s), nonselective
debridement, without anesthesia, including topical application(s), wound assessment, and
instruction(s) for ongoing care, per session (97602 x 2) provided from March 5, 2021, through May 7, 2021.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to
the services 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 $310 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay $1,425.75 which includes the amount of $930 ($310 copayment x 3) for dates of service March 5, 2021, March 12, 2021, and March 19, 2021 for the subcutaneous tissue debridement provided. Additionally, this includes the amount of $495.75 ($165.25 x 3) for dates of service March 26, 2021, April 19, 2021, and May 7, 2021 for other debridement services provided at an outpatient hospital, which is less than the applicable copayments for these 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 copayments for the subcutaneous tissue debridement (11042 x 3), open wound debridement (97597), and the removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia, including topical application(s), wound assessment, and instruction(s) for ongoing care, per session (97602 x 2) provided from March 5, 2021, through May 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse an additional amount for the prefabricated post and core in
addition to crown (D2954), and porcelain crown (D2740) provided on January 4, 2021.
You asked the Plan to reimburse an additional amount for the dental services. You say that the enrollee was
advised they would be reimbursed for dental services up to $2,000. You say that the enrollee was only
reimbursed $650. The Plan denied your request. The Plan says prefabricated post and core in addition to crown
is not listed as a covered service. The Plan says that porcelain crown is not listed as a covered service either.
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 prefabricated post and core in
addition to crown and porcelain crown are not among those covered under this benefit. Therefore, we decided
that the Plan does not have to reimburse an additional amount for the prefabricated post and core in addition to
crown (D2954), and porcelain crown (D2740) provided on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture treatment provided from January 19, 2021, 
through March 2, 2021. 
 
You asked the Plan to pay for acupuncture treatment. You say that you were never told that you had to find an 
acupuncturist in-network. The Plan denied your request. The Plan says non-emergent, non-urgent services with 
out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 acupuncture treatment provided from January 19, 2021, through 
March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to waive the coinsurance charged for orthotics purchased on March 2, 2021.
You asked the Plan to waive this coinsurance. You say that the orthotics did not help your feet and you do not feel you should have to pay for them. The Plan denied your request. The Plan says this cost share was charged based on the claim submitted by the provider and the Plan contract agreement. Any defect to the product itself must be addressed between you and the provider.
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 coinsurance for durable medical equipment. 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 charged for orthotics purchased on March 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 29, 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 physician services provided to the enrollee on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intraoral periapical X-rays (D0230, D0220) and gingival
irrigation (D4921) provided on May 28, 2021.

You asked the Plan to pre-approve intraoral periapical X-rays and gingival irrigation. You say that you do not
believe the benefits at issue have been exhausted for 2021. The Plan denied your request. The Plan says rules
for payment have not been met.

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 1 dental Xray
per year.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of intraoral periapical X-rays have not been met. Specifically, the case record documents that you
received a set of bitewing X-rays at the same visit on May 28, 2021. The benefit for X-rays has been exhausted
for 2021.

We also found that, though the Plan offers a dental benefit in excess of Medicare coverage, gingival irrigation
is not among the items or services covered under this benefit.

Therefore, we decided that the Plan does not have to pre-approve intraoral periapical X-rays (D0230, D0220)
and gingival irrigation (D4921) provided on May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested providers in this case are not network providers with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office consultation to be rendered by the out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omnipod dash insulin cartridges.
You asked the Plan to pre-approve Omnipod dash insulin cartridges. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of your prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Omnipod dash insulin cartridges.
Benefits for Omnipod dash insulin cartridges may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with your
primary care provider (PCP) on April 28, 2021.
You asked the Plan to waive the copayment for the telehealth visit with your PCP. You say that you didn't see
the provider on this date. 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 $5
copayment for primary care visits, including telehealth visits.
Medical records confirm that you had a telehealth visit with your PCP on this date. You have been asked to pay
a $5 copayment for the telehealth visit with your PCP.
Your Evidence of Coverage explicitly states that the same cost sharing applies to telehealth visits as a regular
office visit. 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 telehealth visit you had with your
primary care provider (PCP) on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 14, 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 were not billed correctly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 4, 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 services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an assisted living setting and should have been billed with POS code 13. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy for tooth #2.
You asked the Plan to pre-approve the endodontic therapy. You say that you have partials and you need the root canal done. The Plan denied your request. The Plan says the service is 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 pre-approve endodontic therapy for tooth #2.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility care provided from January 11, 2021, through February 8, 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 services 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 $0 copayment for days 1-20 and a $184 copayment for days 21-100 for inpatient skilled nursing facility care, per benefit period.

You have been asked to pay $1,656 ($184 copayment x 9 days) for the inpatient skilled nursing facility care provided. This copayment applied to days 21-30 of the inpatient stay. 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 skilled nursing facility care provided from January 11, 2021, through February 8, 2021.