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

We decided that the Plan does not have to waive the copayment for the office visit provided on April 19, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you saw the provider and were sent for labs. You say you do not think you should have to pay the copay. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 copayment for primary care provider or other health care professional office visit. You have been asked to pay a $5 copayment for the office visit. The office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on April 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) you had on July 10, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you had MRIs in the past with your previous insurer and you paid much less. 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 $250 copayment for diagnostic radiology services. You have been asked to pay a $250 copayment for the MRI. The MRI falls within the diagnostic radiology services benefit category. This copayment 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 copayment for the magnetic resonance imaging (MRI) you had on July 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam you had on June 16, 2021.
You asked the Plan to waive the copayment for the eye exam. You say that you already paid a copayment to
the provider and you're still receiving a bill. 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 $20
copayment for medical eye exams and routine eye exams.
You have been asked to pay a $20 copayment for the eye exam. 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 eye exam you had on June 16, 2021.
Your complaint about having already paid this amount to the provider 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from December 29, 2020, to January 6, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were charged two different copayments for a single stay. You said that you never left the facility. 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 $250 copayment per day for days 1-8, and a $0 copayment for additional days for inpatient hospital services. Records show that this hospitalization lasted for 8 days. You have been asked to pay a $250 copayment per day
for a total of $2000. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services you received from December 29, 2020, to January 6, 2021.
Please note that the Plan is handling your request regarding your hospital services from January 6, 2021, to January 16, 2021, as a separate case. Please contact the Plan directly with any questions related to these dates of service.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve skilled nursing facility services. You say that this care is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 skilled nursing facility services. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical records
do not show the enrollee requires skilled nursing services with the specialized skill, knowledge and judgment
of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment
in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other
skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the
specialized skill, knowledge, and judgment of a qualified therapist to provide medically necessary and
reasonable treatment safely and effectively in a SNF. The enrollee does not require skilled nursing or skilled
therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this
enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 skilled nursing facility services have not been met. Therefore, we decided that
the Plan does not have to pre-approve skilled nursing facility services
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services.
You asked the Plan to pay for skilled nursing facility services for the enrollee. You say that these services were medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 pay for these services. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found based on the documentation provided, for the dates in question, the enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. Medicare coverage criteria were not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility services provided from July 24, 2021 to July 29, 2021 and from August 10, 2021 to August 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nutrition consultation visits provided on December 15, 2020
to April 14, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for nutrition consultation visits. You say that you have seen this provider in the past
and are not open to seeing an in-network provider. The Plan denied your request. The Plan says the denial of
payment for these services is correct, because this provider is out-of-network with the Plan and authorization
was not 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. Therefore, we decided that the Plan does not have to pay for nutrition consultation visits provided on December 15, 2020 to April 14, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this support will improve your medical conditions. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for lower intestinal endoscopic procedures provided on December 11, 2020.
You asked the Plan to pay for anesthesia for lower intestinal endoscopic procedures. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 December 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 anesthesia for lower intestinal endoscopic procedures provided on December 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says your records do not show that you require skilled nursing services or skilled rehabilitation services. The Plan states the records do not show you require these skilled services on a daily
basis. The Plan states the records do not show that daily skilled services can only be provided on an inpatient basis in a SNF, and the services you require can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.
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 there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. You do not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the long-term care facility appear custodial 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 SNF care
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Hemlibra (J7170).
You asked the Plan to pre-approve Hemlibra. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.
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 Hemlibra. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of Factor VIII replacement product therapy before they will approve the requested drug. It is documented that the enrollee is receiving Factor VIII infusions. It is not documented that this treatment has failed or that Factor VIII replacement product therapy would less effective and/or would likely have adverse effects for the enrollee 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 Hemlibra have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Hemlibra (J7170).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
February 17, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior 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 must 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 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 out of network physician services provided to the
enrollee on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the skin debridement procedure you had
on March 11, 2021, and the wound strapping procedures you had from March 16, 2021, to March 30, 2021, at
an outpatient hospital facility.
You asked the Plan to waive the copayments for the skin debridement and wound strapping procedures. You
say that these services should not be considered surgical services. The Plan denied your request. The Plan says
you were charged these copayments correctly. The Plan stated that for each date of service, because the
allowed charge for the service is less than your copayment obligation, so you are responsible for the full
allowed amount for each.
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 surgery and other services at an outpatient hospital facility.
You have been asked to pay a $350 copayment for the skin debridement and wound strapping procedures.
Medicare considers the services you received to be surgical 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
copayments for the skin debridement procedure you had on March 11, 2021, and the wound strapping
procedures you had from March 16, 2021, to March 30, 2021, at an outpatient hospital facility
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated abutment represented by code D6056, an endosteal implant represented by code D6010, and an implant supported crown represented by code D6065.
You asked the Plan to pre-approve codes D6056, D6010, and D6065. You say that these are not cosmetic services. You say that your dentist advised you that the requested services are needed to fix your dental issues
so that they don't cause issue with your heart. The Plan denied your request. The Plan says the services which remain in dispute are not a covered benefit.
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 which remain in dispute are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a prefabricated abutment represented by code D6056, an endosteal implant represented by code D6010, and an implant supported crown represented by code D6065.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the office visits you had with an orthopedic surgeon on April 30, 2021, and June 2, 2021, and the knee brace you received om May 7, 2021.
You asked the Plan to waive the cost sharing for the specialist visits and the knee brace. You say that this cost sharing should be waived because these services were needed due to after-effects of COVID-19. The Plan denied your request. The Plan says you were charged these cost sharing amounts 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 visits and 20% coinsurance for braces. We looked at the records in this case. The specialist visits and the knee brace were provided to you not
because of COVID-19, but because of osteoarthritis of the knee. You have been asked to pay a $40 copayment per visit for the specialist visits and 20% coinsurance for the knee brace. 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 cost sharing for the office visits you had with an orthopedic surgeon on April 30, 2021, and June 2, 2021, and the knee brace you received om May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 12, 2021.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the diagnosis codes billed on this claim was mismatched.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99214 is Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter. We find that CPT code 99214 is not supported in the medical record. Specifically, this code was billed with diagnosis codes M79.672 (Pain in left foot), S90.424A (Blister (nonthermal), right lesser toe(s), initial encounter)), M14.679 (Charct's joint, unspecified ankle and foot), and M14.671 (Charct's joint, right ankle and foot). These diagnosis codes are mismatched. There are more appropriate diagnosis codes to support bilateral sites. Based on this information, we decided that Medicare rules for coverage of the office visit have
not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided on February
12, 2021