Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for a bone density study provided on February 23, 2021.

You asked the Plan to waive the copayment for a bone density study. You say that this was a preventative bone density scan and you thought that they were fully covered. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that there are no cost-sharing charges for bone mass measurement. 

The record shows that you received a bone density study on February 23, 2021. The billing code on the claim is considered a preventative code for bone mass measurements. The Plan did not provide any documentation indicating that this preventative benefit was exhausted, nor that diagnostic services were received. Therefore, you cannot be asked to pay a copayment for this service. 

The Plan says you must pay a $40 copayment for a bone density study. Based on the Plan contract, however, you cannot be asked to pay for a preventative bone density study. Therefore, we decided that the Plan has to waive the copayment for a bone density study provided on February 23, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transitional care management services (99496) provided on March 25, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for transitional care management services. You say that these services were performed at the dialysis center, and not at the clinic. You also say that you are not aware when authorization is obtained or needed. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory, except when urgent or an emergency.

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. The records provided for review do not show that the services at issue were urgent or emergent. 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 transitional care management services (99496) provided on March 25, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection and physician services provided on April 23, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an injection and physician services. You say that you would like this claim reprocessed and paid. You say that these services were medically necessary for the member. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is also out-of-network.

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 an injection and physician services provided on April 23, 2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on April 22, 2021.

You asked the Plan to waive the copayment for an emergency room visit. You say that you went to the ER because you had a rheumatoid arthritis flare up due to the Covid-19 vaccine. You say that you should not have to pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.

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 an $85 copayment for emergency care.

You have been asked to pay an $85 copayment for an emergency room visit. Since services were provided at the emergency room, the correct copayment has been applied. An emergency room visit 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 an emergency room visit provided by a participating provider on April 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from April 4, 2020, to April 10, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the hospital made you wait until your coronavirus test came back and you were also told that you would not owe anything for the stay because it was related to the coronavirus. 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 $350 copayment for days 1-5 for inpatient hospital care. 

You had an inpatient hospital stay from April 4, 2020, to April 10, 2020. Therefore, you are responsible to pay a $350 (copayment) for days 1-5 (April 4, 2020, to April 8, 2020). However, you are being asked to pay $1,625, which is less than the total copayment amount.

You have been asked to pay $1,650 for an inpatient hospital stay. An inpatient hospital stay falls 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 an inpatient hospital stay provided from April 4, 2020, to April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99204) provided on May 13, 2021.

You asked the Plan to waive the copayment for an office visit. You say that the provider lowered your dosage and advised you to return to your previous primary care physician if you wanted to continue receiving medications over the maximum dispensing limit. The Plan denied your request. The Plan says the copayment you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for physician/practitioner services, including doctor's office visits with a specialist.

You have been asked to pay a $45 copayment for an office visit. The EOC confirms $45 is the required copayment for this service. An office visit with a specialist 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 an office visit with a specialist (99204) provided on May 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Eylea injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that the use of Avastin will not be successful based
on the enrollee's medical history. The Plan denied your request. The Plan says this is not medically necessary.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

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 injection. Our reviewer says that
our physician reviewer found based on the medical records provided, the enrollee has not tried and failed the
plan's required drugs. There is no indication that these drugs would likely be less effective and/or likely have
adverse effects for the enrollee. The provider has stated an opinion that using Avastin will not be successful
based on enrollee's medical history. However, there are no further details to support this opinion. The
remaining step-one medications (Mvasi and Zirabev) remain unaddressed.

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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve an Eylea injection for the enrollee.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says that SNF care is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the requested SNF admission is considered medically reasonable and necessary due to the need for daily skilled therapy services. Our physician reviewer found the enrollee is a female who was treated in the hospital for starvation ketoacidosis with debility after a flare up of trigeminal neuralgia with new right-sided hearing loss. The member's prior level of functioning was that she lived in a private home and was independent with mobility and self-care tasks. The most recent therapy documentation indicates the member requires moderate assistance with bed mobility, maximum assistance with transfers and can only ambulate short distances with a rolling walker. 

The member has stabilized medically and is ready for discharge from the hospital. Although the member does not have any skilled nursing needs, she has had a significant decline in physical functioning. The member does require skilled therapy services on a daily basis at a skilled nursing facility to restore function and avoid further decline or complications. Admission to a skilled nursing facility for inpatient rehab services is medically appropriate. 

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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an outpatient surgery. You say that you would like approval to provide these services. The Plan denied your request. The Plan says there are in-network provides available to provide these services.

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 an outpatient surgery to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0100).

You asked the Plan to pre-approve additional non-emergency transportation trips. You say that you need more
trips for dialysis. The Plan denied your request. The Plan says you have utilized the maximum number of
transportation trips allowed per year.

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 10 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 exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on March 29, 2021.

You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the charges because they did nothing to help you. 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 $55 copayment for urgently needed services. 

You have been asked to pay a $55 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 urgently needed services provided on March 29, 2021.

We note your complaint that the provider did nothing to treat your condition. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on October 13, 2020.

You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the charges because they are higher than a specialist copayment. 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 Medicare Part B prescription drugs. 

You received a Medicare Part B drug on October 13, 2020. The total allowed amount is $1,074.24 and 20% of that is $214.85. 

You have been asked to pay the total coinsurance amount of $214.85 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81545) rendered by the out-of-network
(OON) provider on October 8, 2020.

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 laboratory service (81545)
rendered by the out-of-network (OON) provider on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the endodontic therapy (D3330) provided on April 27, 2021.

You asked the Plan to pay more for the endodontic therapy. You say that you were not told that your insurance would not cover a portion of your root canal until you were numbed and ready for the procedure. You also say that if you had known you would be charged, you would have postponed the procedure until 2022. The Plan denied your request. The Plan says this claim processed correctly for the Plan year. The Plan also says that you had already used your $1,000 comprehensive dental 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 Plan offers an annual benefit maximum of $1,000. The record shows that you met the annual maximum benefit while processing this claim for the April 27, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the endodontic therapy (D3330) provided on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on April 9, 2021.

You asked the Plan to waive the coinsurance for DME. You say that the device was not helpful and you required an amputation. 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 DME on April 9, 2021. The total allowed amount is $929.14 and 20% of that is $185.83. 

You have been asked to pay the total coinsurance amount of $185.83 for DME. DME 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 DME provided on April 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says you are covered for up to 20 one-way trips
per calendar year. The Plan says that you have 8 trips remaining for the benefit year and additional trips will
not be approved.

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 20 one-way transportation trips per year.

We looked at your request, the records in the case file, and the rules. The file shows you are covered for up to
20 one-way trips per calendar year. The Plan says that you have 8 trips remaining for the benefit year and
additional trips will not be approved. Therefore, we decided that the Plan does not have to pre-approve
additional routine transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on April 6, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an x-ray. You say that you would like this claim reprocessed and paid due to medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 an x-ray provided on April 6, 2021 by an out-of-network (OON) provider.