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

We decided that the Plan does not have to pre-approve an out of network provider at the in-network rate.

You asked the Plan to pre-approve out of network services at the in-network rate. You say that you prefer to see the requested out of network provider. The Plan denied your request. The Plan says you have been provided with the names of several in network providers. The Plan states the contract is clear that if you use out of network providers without prior authorization you will pay Original Medicare rates.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan has network providers who can render the treatment needed. Therefore, we decided that the Plan does not have to pre-approve an out of network provider at the in-network rate.
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 these services are medically necessary. The Plan denied your request. The Plan says that your records do not show you have not completed your care in the hospital.

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. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PureWick urinary incontinence system.
You asked the Plan to pre-approve the urinary incontinence system. You say that the medical records provided
will support the necessity of the services. The Plan denied your request. The Plan says this item does not meet
the definition of being durable medical equipment and is not covered.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve the PureWick urinary
incontinence system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May
11, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that you had to go to a new dentist and
the service should be covered. The Plan denied your request. The Plan says the service is a covered benefit, but
you have exceeded the frequency limit of one every 3 Plan years.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a comprehensive oral evaluation have not been met.
Specifically, the record shows that you had exceeded the frequency limit prior to this service on November 5,
2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150)
provided on May 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexilant for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.
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 pre-approve Dexilant for the enrollee.
Benefits for this drug 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility services provided from March 24, 2020, to March 31, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed DPDM is not supported.
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. The documentation provided does not contain medical records from the non-contract provider for the dates of service in question. Without records, it cannot be determined that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility services provided from March 24, 2020, to March 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes with inserts to be provided by an OON
provider.
You asked the Plan to pre-approve the diabetic shoes with inserts. You say that the claims should be paid; you
didn't know it was out of network. The Plan denied your request. The Plan says there are network 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 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
diabetic shoes with inserts to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facial bone graft (21210), lower jaw bone graft (21215), alveoloplasty (41874) and an unlisted dental surgery procedure (41899).
You asked the Plan to pre-approve the dental services. You say that you feel these services should be covered The Plan denied your request. The Plan says these services are not covered by the Plan's dental 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 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a facial bone graft (21210), lower jaw bone graft (21215), alveoloplasty (41874) and an unlisted dental surgery procedure (41899).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on May 5, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Medicare denies a claim for untimely filing if the receipt date applied to the claim exceeds 12
months or 1 calendar year from the date the services were furnished.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the services was not filed until June 19, 2021. This means that more than one
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan
does not have to pay for office visit services provided to the enrollee on May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rural health clinic visit provided on May 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the rural health clinic visit. You say that the claim was resubmitted, and you would like reconsideration of payment. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the rural health clinic visit provided on May 19, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-shares for inpatient hospital care provided on May 25, 2021, to May 27, 2021.
You asked the Plan to waive the cost-shares for inpatient hospital care. You say that you wanted your mother transferred to a different hospital and the hospital did not transfer her till three days later. You also say that your mother should have been transferred immediately and now since the surgery took place that Sunday, she is bed-bound, and the bills keep coming in. The Plan denied your request. The Plan says the cost-shares you are being charged are 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 $500 deductible for all covered medical services. Your contract with the Plan also says that enrollees must pay 10% of the total cost for inpatient hospital care.
You have been asked to pay a $500 deductible and a 10% coinsurance for inpatient hospital care. The service at issue is subject to the Plan deductible of $500. The record shows that at the time this claim was processed, $122.46 of the $500 deductible had been met, resulting in a deductible obligation of $377.54. The records also show that the coinsurance for the inpatient hospital care is $849.76. Your total cost-share is $1,227.30 ($377.54 + $849.76 = $1,227.30), The EOC confirms that 10% is the required coinsurance for this 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 cost-shares for inpatient hospital care provided on May 25, 2021, to May 27, 2021.
Your complaint about the hospital not transferring your mother to a different hospital 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 the inpatient rehabilitation facility (IRF)
admission and services provided August 31, 2020, to September 11, 2020.

You asked the Plan to waive the copayment for the IRF services. You say that you were not informed that the
provider was out-of-network. The Plan denied your request. The Plan says the copayment was 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $325 copayment per day, days 1-6.

The enrollee has been asked to pay a total of $1,950 ($325 copayment x first 6 days = $1,950) for the IRF
services. The IRF stay falls within the Inpatient hospital care benefit category.

This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient rehabilitation facility (IRF) admission and services provided August 31, 2020, to September 11, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services billed with DRG 871 and provided on September 28, 2019, through September 30, 2019.
You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the documentation submitted does not support DRG 871.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not forwarded any clinical records to validate the partial recoupment. The record indicates that the Plan reviewed medical records. Of note, these records were requested and none were received. It is the burden of the Health Plan to substantiate the denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for inpatient hospital services billed with DRG 871 and provided on September 28, 2019, through September 30, 2019.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Medicare Part B drug provided on May 20, 2021.
You asked the Plan to waive the copayment for a Medicare Part B drug. You say that you disagree with the charges because you have never paid more than a $15 copayment in the past. 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 $15 copayment for the total cost of Part B drugs administered by a health care professional.
You have been asked to pay a $15 copayment 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 copayment for a Medicare Part B drug provided on May 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the cardiovascular stress test (93015), the myocardial imaging, positron emission tomography (PET), perfusion study (78492), the technetium tc-99m sestamibi, diagnostic, per study dose (A9500), and the regadenoson injection (J2785) provided on 
December 18, 2020.

You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to 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 20% coinsurance for each Medicare Part B drug. Supplies for which an appropriate separate charge is made by providers (such as, chemical agents used in certain diagnostic procedures) are subject to a 20% coinsurance as shown. Enrollees must pay a $20 copayment for non-radiological diagnostic services. Additionally, enrollees must pay a $110 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).

You have been asked to pay $226.03 which includes the Plan allowed amount of $243.40 x 20% = $48.68 for the chemical agent utilized for the diagnostic procedure, the Plan allowed amount of $236.76 x 20% = $47.35 for the Medicare Part B drug, a $20 copayment for the non-radiological diagnostic service, and a $110 copayment for the radiological diagnostic service 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 cost share for the cardiovascular stress test (93015), the myocardial imaging, positron emission tomography (PET), perfusion study (78492), the technetium tc-99m sestamibi, diagnostic, per study dose (A9500), and the regadenoson injection (J2785) provided on December 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the inpatient hospital.
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 in this case, the enrollee was admitted with diabetic ketoacidosis and atrial fibrillation and found to have multifocal infarcts. The enrollee has had a prolonged hospital course and continues to require critical care services. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.
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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the computed tomography (CT) scan of the chest and the magnetic resonance imaging (MRI) of the brain you had on March 24, 2021.
You asked the Plan to reduce the copayments for the CT scan and the MRI. You say that the facility told you that your copayment would only be $150. The Plan denied your request. The Plan says you were charged these copayments correctly because you had two tests for which copayments are due.
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 $150 copayment for diagnostic and nuclear medicine radiological services.
You have been asked to pay a $150 copayment for the CT scan and the MRI. The CT scan and the MRI fall within the diagnostic and nuclear medicine radiological services benefit category. The Evidence of Coverage states that if you receive multiple test types on the same day, multiple copayments will apply. You had two different test types-- an MRI and a CT scan. That is why two separate $150 copayments 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 reduce the copayments for the computed tomography (CT) scan of the chest and the magnetic resonance imaging (MRI) of the brain you had on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical radiographic images (D0220, D0230 x2)
provided on June 16, 2021.
You asked the Plan to pay for intraoral periapical radiographic images. You say that you disagree with the
Plan's denial. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral
periapical radiographic images (D0220, D0230 x2) provided on June 16, 2021.