Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the home health (HH) skilled nursing (SN) services (CPT code G0299 x2), for the enrollee.       You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says per the enrollee's recent records their medical conditions appear stable. The Plan states there have been no recent changes to their treatment plan or the enrollee's medications. The Plan states the enrollee's records show that their medical conditions, medication management, pain management, diet, and household safety have been reviewed and education has been provided. The Plan states the enrollee's records do not support the need for a skilled nurse to make more visits.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 physician reviewer found the health plan's denial should be upheld. The enrollee does not have documented, ongoing, skilled nursing needs. The enrollee lives in a staffed facility and has family assistance as needed. The enrollee sees medical personnel regularly at dialysis appointments. As such, the requested, ongoing, HH SN visits are not medically necessary or reasonable.  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 the home health (HH) skilled nursing (SN) services (CPT code G0299 x2), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from April 27, 2021, to May 4, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel the facility has overcharged for the services. 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 $175 per day for days 1-7 and $0 per day for days 8-90 for each inpatient admission. 

The file shows that you were in the hospital from April 27, 2021, to May 4, 2021. Therefore, you have been asked to pay $175 per day for the first 7 days of inpatient hospital services. The total for your stay is $1225 ($175 copayment x 7 days = $1225). The inpatient hospital services fall within the Inpatient Hospital 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 inpatient hospital services provided from April 27, 2021, to May 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy (CPT code(s): 97163 x1, 97112 x16, 97110 x 16, 97530 x16) to be provided by an out-of-network provider.

You asked the Plan to pre-approve physical therapy. You say that the services are necessary. The Plan denied your request. The Plan says they have contacted participating providers within a serviceable distance from the enrollee and determined that the enrollee could receive the needed services within a reasonable timeframe at the in-network benefit level; therefore, no network deficiency exists.

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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy (CPT code(s): 97163 x1, 97112 x16, 97110 x 16, 97530 x16) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and out of network cost share amount for the root canal (D3330) and prefabricated post and core in addition to a crown (D2954) provided on November 1, 2021, by the out of network dentist.

You asked the Plan to waive the deductible and out of network cost share amount for the dental services. You say that you were not aware of the dental deductible and coinsurance. You say that you were only advised that the plan would pay $1,000 for your supplemental dental services. The Plan denied your request. The Plan says there is a $100 deductible for dental services you receive, regardless or the provider's network status. The Plan says that you pay 55% for endodontic services. The Plan says you pay 50% for restorative services. The Plan also says that when you receive this services out of network, you are responsible for balances up to the dentist's charge.

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 and the services are listed as covered, there are cost share amounts that apply. The record shows that the $100 deductible was correctly applied to the root canal as it had not been met prior to the date of service in this case. The record shows that you pay 55% for endodontic services, including a root canal. The record shows that you pay 50% for restorative services, including a post and core in addition to a crown. Since the provider in this case is out of network, you are responsible for balances up to the dentist's charge. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Additionally, the record shows that you were given correct information by the plan representative. Therefore, we decided that the Plan does not have to waive the deductible and out of network cost share amount for the root canal (D3330) and prefabricated post and core in addition to a crown (D2954) provided on November 1, 2021, by the out of network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for home health agency care services provided on August 18, 2021, by an OON provider.  You asked the Plan to pay for the home health agency care services. You say that the hospital staff failed to get prior authorization. The Plan denied your request. The Plan says there was no prior approval from the primary care physician. Therefore, services rendered from a non-participating provider was denied.  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 home health agency care services provided on August 18, 2021, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for a diagnostic colonoscopy (45378) rendered on September 3, 2021.

You asked the Plan to reduce the copayment for a diagnostic colonoscopy. You say that this was a normal colonoscopy, which has no copayment. You also say there were no hemorrhoids or diverticulosis. You also say that you are paying $40 for the visit. The Plan denied your request. The Plan says you were 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 a diagnostic colonoscopy is performed in order to explain symptoms identified by your physician, because you have had a previous colonoscopy that resulted in removal of polyps, or other colorectal related conditions. The Plan contract also says that if your physician orders a diagnostic colonoscopy see "outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" for cost share. The Plan contract also says that enrollees must pay a $325 copayment for outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $325 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. The record shows that this was a diagnostic colonoscopy and not a screening colonoscopy. 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 reduce the copayment for a diagnostic colonoscopy (45378) rendered on September 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Rocklatan drops, for the enrollee.  You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says Rocklatan is a self-administered drug. The Plan states the enrollee does not have pharmacy (drug) benefits administered from this health 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 Rocklatan drops, for the enrollee.   Benefits for the medication 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0483) provided on May 4, 2021.  You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transportation, taxi (A0100), provided on
September 28, 2021.

You asked the Plan to pay for the routine transportation. You say that when you signed up for your plan you
were advised you were covered for 50 trips. You say that nothing was to be deducted from your coverage. You
also say that the medical trips were reduced instead. The Plan denied your request. The Plan says 24 one-way
trips are covered. The Plan also says that the benefit has been exhausted.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 24 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exceeded the Plan maximum benefit for coverage of routine transportation. The record shows
that the Plan paid for 29 one-way trips. Therefore, we decided that the Plan does not have to pay for non-emergency
transportation, taxi (A0100), provided on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for podiatry office visits provided on April 29, 2021, and October 21, 2021.  You asked the Plan to waive the copayment for the office visits. You say that you disagree with the copayments because they were routine diabetic visits. You say you feel you were misled since you were not made aware of any exceptions to the copayment for routine visits. The Plan denied your request. The Plan says the cost-share was applied correctly. The Plan says the medical records indicate you were seen for routine foot care as well as additional conditions. The Plan further states the treatment of additional conditions outside the scope of a routine podiatry visit nullifies the "routine visit" component.  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 $45 copayment for Podiatry Services.   You have been asked to pay a $90 copayment for podiatry office visits. The services at issue fall within the Podiatry 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 podiatry office visits provided on April 29, 2021, and October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 31, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the provider did not look at your shoulder or collar bone and you feel that you do not owe the 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 $35 copayment for each 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.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation trips.

You asked the Plan to pre-approve routine transportation trips. You say that you need transportation to office visits. The Plan denied your request. The Plan says that you have not had any recent emergency room visits.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a one-way trip to the home for continued acute care after discharge from an emergency room and any additional trips to a physician related to the continued acute home care.

We looked at your request, the records in the case file, and the rules. The file does not indicate you have had a recent emergency room visit. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for an arthrocentesis, aspiration and/or injection (20610) rendered on May 6, 2021.  You asked the Plan to waive the deductible for an arthrocentesis, aspiration and/or injection. You say that this should have been covered and not applied to the deductible, which is for hospital services. You also say that you did not go to the operating room (OR), only the provider's office. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.    The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says the "deductible" is the amount you must pay for medical services before the Plan begins to pay its share. The Plan contract says that there is a $750 deductible for all items and services specifically listed in the Plan contract. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. The Plan deductible applies to an arthrocentesis, aspiration and/or injection. The Plan contract also says that there is a $350 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 a $276.23 deductible for an arthrocentesis, aspiration and/or injection. An arthrocentesis, aspiration and/or injection falls within the benefit category outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. The deductible is a contractual obligation that had not been met at the time an arthrocentesis, aspiration and/or injection was received on May 6, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an arthrocentesis, aspiration and/or injection (20610) rendered on May 6, 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 no documentation that the member has had prior complications with anesthesia, emergent surgery, or there is an expectation that surgery would be complex.  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. The documentation indicates that the enrollee is medically stable. She has no medical issues that would require an inpatient level of care after the procedure. There is no documentation that the member had prior complications with anesthesia or any expectation that surgery would be complex. The record does not show that at the time of inpatient admission the admitting physician reasonably expects that the patient's necessary hospital care would span two midnights. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), intraoral x-rays (D0220 and D0230), two resin-based composites (D2330 x2), three simple extractions (D7140 x3), comprehensive oral evaluation (D0150), and complete series of intraoral x-rays (D0210) provided from May 5, 2021, to August 12, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the problem focused limited oral evaluation, intraoral x-rays, resin-based composites, simple extractions, comprehensive oral evaluation, and complete series of intraoral x-rays. You say that you lost a tooth overnight, were in great pain, and did not look for an in-network dentist. You also say that before you had a chance to follow up another tooth fell out, as did an old filling. The Plan denied your request. The Plan says services need to be provided in-network to be eligible for payment.  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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), intraoral x-rays (D0220 and D0230), two resin-based composites (D2330 x2), three simple extractions (D7140 x3), comprehensive oral evaluation (D0150), and complete series of intraoral x-rays (D0210) provided from May 5, 2021, to August 12, 2021 by an out-of-network (OON) provider.