Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for telephone evaluations provided on September 1, 2021, and September 7, 2021.  You asked the Plan to waive the copayments for telephone evaluations. You say that the services were related to your coronavirus diagnosis so you should not be responsible for 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 a $10 copayment for telephonic medical consultations.  You received telephone evaluations on September 1, 2021, and September 7, 2021. This service does not qualify for the coronavirus waiver.  Therefore, you are responsible to pay a $10 copayment per each telephone evaluation. The total amount you owe is: $20.   You have been asked to pay the total copayment amount of $20 for telephone evaluations. Telephone evaluations fall 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 copayments for telephone evaluations provided on September 1, 2021, and September 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre Sensor.  You asked the Plan to pre-approve a Freestyle Libre Sensor. You say that the item is medically necessary. The Plan denied your request. The Plan says the member is not insulin treated.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre Sensor.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) (G0299).  You asked the Plan to pre-approve the direct skilled nursing services of a RN. You say that the enrollee has several chronic conditions that qualify him to continue home health care. The Plan denied your request. The Plan says that criteria are not met for continued home health nursing 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 direct skilled nursing services of a RN. Our reviewer says that the requested, ongoing, home health skilled nursing services are not medically necessary or reasonable. Our physician reviewer found the enrollee does not have documented skilled nursing needs.  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 direct skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).  You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the item is medically necessary. The Plan denied your request. The Plan says the member is not insulin treated.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 11, 2021.  You asked the Plan to pay for the dental service. You say that your regular dentist referred you to an endodontist. You also say that you only went to the specialist once and do not understand how that could be too frequent. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit 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 and limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on August 24, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided from January 3, 2021, to January 7, 2021.

You asked the Plan to waive the copayment for outpatient hospital observation. You say that you were in the hospital due to having the coronavirus and should not be responsible for 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 a $350 copayment for outpatient hospital observation. 

The medical records show that you received outpatient hospital observation from January 3, 2021, to January 7, 2021. The record shows that this stay does not qualify for the coronavirus waiver. Therefore, you are responsible to pay the $350 copayment. 

You have been asked to pay a $350 copayment for outpatient hospital observation. Outpatient hospital observation falls within the outpatient hospital observation 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 outpatient hospital observation provided from January 3, 2021, to January 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan provided from a network provider on September 20, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that the CT scan should be fully covered since it was needed for your knee replacement operation. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.     The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in an in-network physician's office or at an in-network free-standing facility (such as a radiology center or medical clinic). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $160 copayment for the CT scan.  You have been asked to pay a $143.30 copayment for the CT scan. The CT scan falls within "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows the CT scan was considered a separate service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan provided from a network provider on September 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the bevacizumab injection (J9035) provided on March 8, 2021.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the item 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 20% coinsurance for Medicare Part B covered drugs.

You have been asked to pay $10.52 (Plan allowed amount of $52.61 x 20% coinsurance) for the Medicare Part B drug injection provided. 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 bevacizumab injection (J9035) provided on March 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on September 6, 2021.

You asked the Plan to pay for a diagnostic or therapeutic injection. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a diagnostic or therapeutic injection have not been met. Specifically, the case record does not contain documentation to support the medical necessity of the services at issue. Therefore, we decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on September 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a tendon sheath incision of the finger (26055) provided on August 16, 2021.  You asked the Plan to waive the copayment for the tendon sheath incision of the finger. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $295 copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers.   You have been asked to pay a $295 copayment for a tendon sheath incision of the finger. Tendon sheath incisions fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 tendon sheath incision of the finger (26055) provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on October 22, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that services were provided to the enrollee out of medical necessity. The Plan denied your request. The Plan says both the referring and attending providers are non-participating provider and there was no request for 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 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 office visit provided on October 22, 2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs received while in the hospital provided on October 5, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you believe these should be covered. The Plan denied your request. The Plan says the claim has processed correctly in this case.  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 pay for the self-administered drugs received while in the hospital provided on October 5, 2021.   Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids (V5261) purchased on April 30, 2021.  You asked the Plan to pay for the hearing aids. You say that you were told by a customer service representative that you could be reimbursed for these hearing aids, and this provider is part of the Plan's network. The Plan denied your request. The Plan says the provider in this case is not part of the Plan's routine hearing vendor network. You are responsible for all costs for hearing aids purchased outside of this vendor network.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased from the Plan's specified routine hearing vendor.   We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's routine hearing vendor network, which is not the same as the Plan's medical network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) purchased on April 30, 2021.   Your complaint about potential misinformation from a Plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for debridement of nails provided on August 25, 2021, by an OON provider.  You asked the Plan to pay for the debridement of nails. You say that services were provided to the enrollee. The Plan denied your request. The Plan says there was no prior authorization, and the provider is not a network provider.   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 debridement of nails provided on August 25, 2021, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing services provided from September 7, 2021, to October 6, 2021.    You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the SNF continued stay was denied for skilled nursing care because the enrollee required no nursing services which would be considered skilled services by Medicare.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a skilled nursing facility (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 skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 7, 2021, to October 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the echocardiogram provided by an in-network facility on September 9, 2021.  You asked the Plan to waive the copayment for the echocardiogram. You say that you had no option to have the echocardiogram performed in the office for a lower copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for diagnostic procedures at an in-network hospital.    You have been asked to pay a $100 copayment for the echocardiogram. The echocardiogram falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the echocardiogram provided by an in-network facility on September 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on August 23, 2021.  You asked the Plan to pay for a diagnostic or therapeutic injection. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.    The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a diagnostic or therapeutic injection have not been met. Specifically, the case record does not contain documentation to support the medical necessity of the services at issue. Therefore, we decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (88112) provided on September 24, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for laboratory services. You say that the patient does not go directly to your laboratory, so he/she is not using out-of-network benefits as his/her participating doctor sends you the specimens to process. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services (88112) provided on September 24, 2021, by an out-of-network (OON) provider.