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

 We decided that the Plan does not have to waive the copayment for ambulance services you received on June 30, 2020.  You asked the Plan to waive the copayment for the ambulance services. You say that this copayment should be waived because you were admitted to the hospital the day after the ambulance services. The Plan denied your request. The Plan says you were not admitted to the hospital, so the copayment applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for ambulance services.   You have been asked to pay a $250 copayment for the ambulance services. Records show that you were never admitted as an inpatient to the hospital.  Rather, you were kept in observation, which is an outpatient status. As a result, the ambulance copayment applies. 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 ambulance services you received on June 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for surgical services provided by a pain management doctor on July 15, 2021, and July 29, 2021.  You asked the Plan to waive the copayments for the specialist services. You say that you don't think it's fair that you have to pay the facility and a separate charge for the doctor. The Plan denied your request. The Plan says you were charged these copayments correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment per visit for specialist medical care or surgery services furnished in a physician's office, ambulatory surgical center, hospital outpatient department, or any other location.   You have been asked to pay a $40 copayment per visit for the specialist services. Your contract says that you pay a separate copayment for specialist medical care or surgery services furnished in a physician's office, ambulatory surgical center, hospital outpatient department, or any other location 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 surgical services provided by a pain management doctor on July 15, 2021, and July 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation hospital care provided from April 22, 2021, through April 23, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $225 copayment per day, for days 1-7 for inpatient hospital care. Inpatient hospital care includes inpatient acute, inpatient rehabilitation, long-term hospitals and other types of inpatient hospital services.  You have been asked to pay $225 ($225 copayment x 1 day) for the inpatient rehabilitation hospital care 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 copayment for the inpatient rehabilitation hospital care provided from April 22, 2021, through April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator.  You asked the Plan to pre-approve the requested services. You say that you are unable to carry the big tanks. The Plan denied your request. The Plan says the documentation does not indicate lightweight tanks do not satisfy your needs within the home.  The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home.  We looked at the file, and Medicare rules. The file shows that the requested item is needed to go out of the house. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.   Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's status is stable and improving. The enrollee is receiving medically necessary acute and/or critical care at the current facility. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which the LTACH may offer a therapeutic advantage.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Regadenoson injection you received on July 6, 2021.  You asked the Plan to waive the coinsurance for the Regadenoson injection. You say that you feel as though you should have been advised at the time of the procedure that there would be a separate charge for this drug.  You said that this test cannot be administered without this drug. 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 Medicare Part B drugs.   You have been asked to pay 20% coinsurance for the Regadenoson injection. The Regadenoson injection falls within the Medicare Part B drugs benefit category. Your contract says that this category includes drugs you receive while getting other services, so it is clear that separate cost sharing can apply. 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 Regadenoson injection you received on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the implant/abutment supported removable denture for the lower arch (D6111) provided on July 6, 2021.  You asked the Plan to pay for the dental service. You say that you feel this should be covered. You also say that the denture will snap into place utilizing two posts that are already in your mouth. The Plan denied your request. The Plan says the implant/abutment supported removable denture for the lower arch is not listed as 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.  Though the Plan offers a dental benefit in excess of Medicare coverage, the implant/abutment supported removable denture for the lower arch is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the implant/abutment supported removable denture for the lower arch (D6111) provided on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital services provided from December 8, 2020, through December 9, 2020.  You asked the Plan to pay for the hospital services. You say that you would like these medical services reprocessed based on the medical documentation provided. The Plan denied your request. The Plan says this claim has been submitted with a procedure code that, based on the OCE, will result in a denial of payment for all services.  The Plan must follow Medicare rules. Medicare rules say that code 96040 has a Status Indicator of B and is not  payable under the Outpatient Prospective Payment System. Medicare rules state that a code with Status  Indicator B results in an I/OCE edit of 62, meaning that the whole claim will be rejected and returned to the  provider until the error is corrected.  We looked at the file and Medicare rules. Code 96040 has a Status Indicator of B and is not payable. We  reviewed the I/OCE Specifications file for this date of service. OCE Edit 62 is invoked when a code has a  Status Indicator of B. The required disposition for a claim with this edit is Return To Provider. This means the  whole claim is returned to the provider. The provider can resubmit the claim once the problem is corrected. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital services provided from December 8, 2020, through December 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genicular nerve block provided on August 3, 2021.  You asked the Plan to pay for the nerve block. The Plan denied your request. The Plan says this is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 nerve block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that a genicular nerve block is considered an experimental/investigational procedure. The role of nerve blocks and radiofrequency ablation (RFA) of the genicular nerves is still the subject of ongoing clinical trials. Therefore, at this time, this request is considered not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the nerve block have not been met. Therefore, we decided that the Plan does not have to pay for the genicular nerve block provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve electrical stimulation therapy to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are available in-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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve electrical stimulation therapy to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a non-covered item, battery backup for a CPAP (A9270).  You asked the Plan to pre-approve a battery backup. You say that you are requesting a batter for the new equipment that was changed by recall. The battery you received in 2018 was for the other CPAP which is no longer compatible. The Plan denied your request. The Plan says Medicare does not allow payment for power generators or alternative power sources needed in the event of power outages.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a non-covered item, battery backup for a CPAP (A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve orthopedic services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. You say that you have tried doctors here with no success. The Plan denied your request. The Plan says there are local providers available.  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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve orthopedic services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for services provided by a nurse practitioner in a pain management specialist's office.  You asked the Plan to waive the copayment for the nurse practitioner specialist services. You say that you were only seen by a nurse practitioner, not a physician.  You do not think you should have to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for physician/practitioner specialist visits.   You have been asked to pay a $40 copayment for the nurse practitioner specialist services. This copayment applies to both physician and practitioner services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for services provided by a nurse practitioner in a pain management specialist's office.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and 2 additional periapical x-rays (D0230) provided on June 22, 2021.  You asked the Plan to pay for the dental services. You say that your new dentist did additional x-rays that your previous dentist never did. You say that you did not know they were not covered until you received a bill for $41. You also say that you feel you did not need the extra x-rays. The Plan denied your request. The Plan says periapical x-rays are not listed as covered.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and 2 additional periapical x-rays (D0230) provided on June 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient care provided from February 2, 2020, to February 3, 2020, and billed with DRG (diagnosis related group) 190.  You asked the Plan to pay for inpatient care. You say that the billed DRG was correct. The Plan denied your request. The Plan says the documentation does not support diagnosis J96.01, acute respiratory failure with hypoxia.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with DRG 190, chronic obstructive pulmonary disease with major complications or comorbidities. 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 inpatient care. Our reviewer says that the billed DRG is not supported. Our physician reviewer found the pulmonology notes in the submitted records document that the enrollee did not have respiratory distress. There is no documenation of treatment consistent with acute respiratory failure.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient care provided from February 2, 2020, to February 3, 2020, and billed with DRG (diagnosis related group) 190.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pelvic floor stimulator obtained on February 25, 2021.  You asked the Plan to pay for this equipment. You say that this equipment was medically necessary, and you have seen your physician for treatment of your condition. The Plan denied your request. The Plan says you obtained this equipment out of network without a physician order. The Plan states no medical records were submitted to show this device was medically necessary or ordered by your physician's office.   Medicare rules say that plans can require enrollees to get prior authorization. Medicare rules say that durable medical equipment requires a physician order prior to purchase. The contract with the Plan says that durable medical equipment requires prior authorization. You purchased this equipment out of network without prior authorization. You did not have a physician order prior to the purchase. The Plan was unable to obtain records from your physician to support this purchase. Therefore, we decided that the Plan does not have to pay for the Attain device (pelvic floor stimulator) obtained on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the biopsy procedure you had at an outpatient hospital facility on July 22, 2021.  You asked the Plan to waive the copayment for the biopsy procedure. You say that you were advised by your provider to have this service, but you were not advised how much it would cost. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for outpatient hospital services.   You have been asked to pay a $275 copayment for the biopsy procedure. The biopsy procedure falls within the outpatient hospital 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 the biopsy procedure you had at an outpatient hospital facility on July 22, 2021.