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

We decided that the Plan does not have to waive the copayment for emergency care provided on September 12, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because nothing was done for you at the emergency room. 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 $90 copayment for emergency care. The medical records show that you received emergency care on September 12, 2021. Therefore, you are responsible to pay the $90 copayment. You have been asked to pay a $90 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 on September 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an apixoectomy-molar (D3425), a retrograde filling (D3430), and a bone graft in conjunction with periradicular surgery (D3428) provided by a participating provider on April 23, 2021.

You asked the Plan to pay for an apixoectomy-molar, a retrograde filling, and a bone graft in conjunction with periradicular surgery. You say that you had an infection for four years. You say that you cannot afford the remaining balance. The Plan denied your request. The Plan says the dental services that were provided are not covered benefits.

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 an apixoectomy-molar (D3425), a retrograde filling (D3430), and a bone graft in conjunction with periradicular surgery (D3428) provided by a participating provider on April 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (64490, 62370) provided on June 10, 2020.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were non-emergent and not pre-authorized.

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 services 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 these services. Therefore, we decided that the Plan does not have to pay for surgical services (64490, 62370) provided on June 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on May 7, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your vitals were taken, a heart monitor was put on you, your blood sugar was alright, and you started to feel better. The Plan denied your request. The Plan says ambulance response and treatment with no transport is not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on May 7, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on May 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Continued care in the acute inpatient rehabilitation facility is appropriate (and endorsed by the health plan) until you are stable to transfer to a lower level of care such as home with home health 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided May 10, 2021.
You asked the Plan to pay for the limited oral exam and two tooth extractions. You say that your provider quoted you a price that is less than what is now being charged. The Plan denied your request. The Plan says the claims have been reprocessed as in-network; however, you have exceeded the frequency limit for tooth extracts and the limited oral exam is not a covered service.
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 two tooth extractions with 50% coinsurance per calendar year.
We looked at the file and Medicare rules. In this case the Plan provided documentation showing that two tooth extractions were covered with 50% coinsurance on the same date of service. Based on this information, we decided that the Plan's frequency limit for coverage of the tooth extractions has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the limited oral exam is not among those covered services. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided May 10, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided this enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case. 

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia service rendered on April 28, 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 procedure code 99100 is 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 99100 (special anesthesia service) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the special anesthesia service rendered on April 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided this enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Continued care in the acute inpatient rehabilitation facility is appropriate (and endorsed by the health plan) until the enrollee is stable to transfer to a lower level of care such as home with home health 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand finger orthosis (WHFO), without joint(s), prefabricated, off-the-shelf, any type (L3809) provided May 17, 2021.

You asked the Plan to pay for the orthosis. You say that this item/order was dispensed from a stock and bill closet at the hospital, therefore the prescription and proof of delivery are both on one page. The Plan denied your request. The Plan says the provided documentation provided by the supplier does not meet the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) criteria.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the wrist hand finger orthosis (WHFO), without joint(s), prefabricated, off-the-shelf, any type (L3809) provided May 17, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent observation care (99225), subsequent hospital care (99232), and hospital discharge day management (99239) provided from February 8, 2020, to February 10, 2020.
You asked the Plan to pay for the subsequent observation care, subsequent hospital care, and hospital discharge day management. You say that you billed hospice for the date of service and were advised that the patient was not enrolled at the time of service. You also say that you would like this claim to be reprocessed for payment. 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on February 7, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent observation care (99225), subsequent hospital care (99232), and hospital discharge day management (99239) provided from February 8, 2020, to February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the LifeVest you rented on June 23, 2021.
You asked the Plan to waive the coinsurance for the LifeVest. You say that this bull was a surprise and totally
unexpected. You said that the LifeVest was prescribed to save your life and is necessary. The Plan denied your
request. The Plan says you were charged this coinsurance correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for durable medical equipment.
You have been asked to pay 20% coinsurance for the LifeVest. The LifeVest falls within the durable medical
equipment 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 LifeVest you rented
on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) and first intraoral periapical x-ray (D0220) provided on July 19, 2021.
You asked the Plan to pay for the removal of residual tooth roots and first intraoral periapical x-ray. You say that these services were provided due to a root left in that caused you pain from an infection. The Plan denied your request. The Plan says removal of residual tooth roots is not a covered expense under your dental plan. The Plan also says that your benefits for the first intraoral periapical x-ray have been satisfied and the frequency limitation has been exceeded.
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, removal of residual tooth roots (D7250) is not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) on June 14, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) and first intraoral periapical x-ray (D0220) provided on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second day of repeat trigger point injections.
You asked the Plan to pre-approve the second day. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation in the medical record must support the medical necessity and frequency of the trigger point injections.
The Plan must follow Medicare rules. Medicare rules say that the documentation in the medical record must support the medical necessity and frequency of the trigger point injection(s 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 second day. Our reviewer says that the requested additional day of services are not considered medically reasonable and necessary in this case. Our physician reviewer found only one day of trigger point injection is medically reasonable and necessary. A
request for a second injection should be made only after an evaluation of the effectiveness of the injection has been made. 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 second day have not been met. Therefore, we decided that the Plan does not have to pre-approve a second day of repeat trigger point injections
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs you received from June 4, 2021, to June 24, 2021.

You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you received chemotherapy in 2019 and never had to pay for it before. You said that you cannot afford this coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for chemotherapy drugs and administration. 

You have been asked to pay 20% coinsurance for the chemotherapy drugs. This coinsurance applies regardless of what you may have paid in the past. 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 chemotherapy drugs you received from June 4, 2021, to June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on May 28, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the domiciliary visit. You say that the service was medically necessary, and you were unaware the facility failed to get pre-authorization for the enrollee. The Plan denied your request. The Plan says no prior authorization was obtained.

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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on May 28, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a walking boot provided on April 29, 2021.

You asked the Plan to waive the coinsurance for a walking boot. You say that you found the boot online for cheaper and disagree with 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 20% coinsurance for DME and related supplies. 

You received a walking boot on April 29, 2021. The total allowed amount is $260.69 and 20% of that is $52.14. You have been asked to pay the total coinsurance amount of $52.14 for a walking boot. A walking boot falls within the DME and related 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 a walking boot provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the skin lesion removal procedure you had at an outpatient hospital facility on July 12, 2021.

You asked the Plan to reduce the copayment for the skin lesion removal procedure. You say that you go to three doctors at this facility and only pay a copayment. You said that this is not an outpatient hospital setting. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($159.02) is less than your copayment obligation, you are responsible for the full allowed amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for surgery services in an outpatient hospital facility.

You have been asked to pay a $275 copayment for the skin lesion removal procedure. The facility where you received these services bills as an outpatient hospital facility. That is why the skin lesion removal procedure fall within the surgery services in an outpatient hospital facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the skin lesion removal procedure you had at an outpatient hospital facility on July 12, 2021.