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

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received from May 1, 2021, to May 21, 2021.

You asked the Plan to waive the copayment for the SNF services. You say that you did not know about this copayment and you do not have time to verify your coverage. You also claim that you were discharged from the hospital (where you were before the SNF stay) too early. 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 $01 copayment for days 1-20, and a $135 copayment per day for days 21-100 for skilled nursing facility services.

Records show you were in a SNF from April 19, 2021, to April 23, 2021. You were not charged a copayment for these four days. You were then transferred to another SNF, where you stayed from April 23, 2021, to May 21, 2021, for 28 days. You were not charged a copayment for the first 16 days of this stay, since you still had 16 days remaining where $0 copayment would apply. For the last 12 days of the stay, you were charged a copayment of $135 per day, for a total of $1620. 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 skilled nursing facility (SNF) services you received from May 1, 2021, to May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee arthroplasty (CPT code 27447-AS-RT) provided to the enrollee on May 10, 2021, by the LSA.

You asked the Plan to pay for the knee arthroplasty. You say that the LSA was called in to assist the doctor on this case. You state both the primary surgeon and the facility are in-network, the CPT codes billed are payable to the assistant surgeon, and you would like for the assistant surgeon's claim to be processed at the in-network rate. The Plan denied your request. The Plan says the services of Surgical Technicians and RN First Assists (RNFA) are not eligible for separate reimbursement. The Plan states these services are being billed by an ineligible provider.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee arthroplasty have not been met.

The documentation submitted indicates that assistant surgical services were performed by a Surgical Technologist/ Surgical First Assistant (CST/CSFA), LSA. Although skilled, certified surgical technicians are not recognized for payment per the Center for Medicare/Medicaid Services (CMS) guidelines. Therefore, we decided that the Plan does not have to pay for the knee arthroplasty (CPT code 27447-AS-RT) provided to the enrollee on May 10, 2021, by the LSA.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) provided March 29, 2021, and the crown - porcelain fused to noble metal (D2752) provided April 15, 2021.
You asked the Plan to pay for the prefabricated post and core and the crown. You say that you feel the crown services should be covered at 50% because your root canal was covered at 50%. The Plan denied your request. The Plan says these services are not covered under your 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 the prefabricated post and core in addition to crown (D2954) provided March 29, 2021, and the crown - porcelain fused to noble metal (D2752) provided April 15, 2021.
Your complaint about which service are and are not covered by the Plan 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) and oral hygiene instructions (D1330) provided April 19, 2021, limited oral evaluation - problem focused (D0140), pulp vitality tests (D0460) provided April 28, 2021, limited oral evaluation - problem focused (D0140) provided May 28, 2021, and limited oral evaluation - problem focused (D0140), bone replacement graft - retained natural tooth - first site in quadrant (D4263), and guided tissue regeneration - resorbable barrier, per site (D4266) provided June 1, 2021.
You asked the Plan to pay for the 2D photographic images, oral hygiene instructions, limited oral exams, bone replacement graft and guided tissue regeneration. You say that the services were an emergency and should be covered. The Plan denied your request. The Plan says these services are not covered under your 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 the 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) and oral hygiene instructions (D1330) provided April 19, 2021, limited oral evaluation - problem focused (D0140), pulp vitality tests (D0460) provided April 28, 2021, limited oral evaluation - problem focused (D0140) provided May 28, 2021, and limited oral evaluation - problem focused (D0140), bone replacement graft - retained natural tooth - first site in quadrant (D4263), and guided tissue regeneration - resorbable barrier, per site (D4266) provided June 1, 2021.
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 the enrollee had a very long complicated hospital course, and she is now recommended for the LTACH level of care. The Plan denied your request. The Plan says that as acute care hospitals and LTACHs are licensed to provide the same level of care, there is no advantage in moving the enrollee from the current acute care hospital to an LTACH.
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 that LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. The requested LTACH
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 waive the coinsurance for the back brace you received on April 5, 2021.
You asked the Plan to waive the coinsurance for the back brace. You say that you only used the braise once because it was painful and useless to you. You said that you were never told there would be a charge for this brace and you cannot afford it. 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 prosthetics and orthotics (including braces). You have been asked to pay 20% coinsurance for the back brace. The back brace falls within the prosthetics and orthotics benefit category. This coinsurance applies regardless of whether you actually use the device or not. 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 back brace you received on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the electrocardiogram (ECG) you had on December 9, 2020, the transthoracic echocardiogram (TTE) you had on December 17, 2020, and the myocardial perfusion imaging, adenosine injection, and stress test you received on December 31, 2020.
You asked the Plan to waive the cost sharing for the ECG, TTE, myocardial perfusion imaging, adenosine injection, and stress test. You say that you believe you should only owe $6.04 for these services. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that for the ECG you had on December 9, 2020, the allowed amount for this service ($17.09) is less than your copayment obligation, so you are responsible for the full allowed 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 $25 copayment for non-radiological diagnostic services, a $150 copayment for radiological diagnostic services, and 20% coinsurance for Medicare Part B drugs. You have been asked to pay a $25 copayment for the ECG, a $25 copayment for the TTE, a $150 copayment for the myocardial perfusion imaging, 20% coinsurance for the adenosine injection, and a $25 copayment for the stress test. The ECG, TTE, and stress test fall within the non-radiological diagnostic services benefit category. The myocardial perfusion imaging falls in the radiological diagnostic service benefit category. The adenosine injection is a Medicare Part B drug. This means that you have been asked to pay the correct amounts 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 electrocardiogram (ECG) you had on December 9, 2020, the transthoracic echocardiogram (TTE) you had on December 17, 2020, and the myocardial perfusion imaging, adenosine injection, and stress test you received on December 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on March 12, 2021.

You asked the Plan to pay for foot orthotics. You say that the enrollee's plantar fasciitis is painful, tender, and stiff that is interfering with daily life activities. 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 pay for foot orthotics provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vitamin b-12 cyanocobalamin, up to 1000 mcg injection (CPT code J3420) and therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (CPT code 96372) provided on May 17, 2021, and June 14, 2021.

You asked the Plan to pay for the services. You say that the services should be covered. The Plan denied your request. The Plan says the services are considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Review of the file shows that you received the office services (CPT code 99212-25), vitamin b-12 cyanocobalamin, up to 1000 mcg injection (CPT code J3420) and therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (CPT code 96372) for dates of service May 17, 2021, and June 14, 2021. You were asked to pay a $35 copayment for the office services (CPT code 99212-25) on each date of service. 

However, both CPT code(s): J3420 and 96372 for both dates of service are denied from coverage because B-12 injections are not covered because the Food and Drug Administration (FDA) has not approved B-12 injections for the treatment of telogen effluvium. Your EOC states that drugs used for conditions not approved by the FDA are excluded from coverage. Your 2021 EOC states drugs (Part B under your medical benefit) - (non-chemotherapy and biologicals) used for conditions not approved by Food and Drug Administration (FDA), such as biomedical hormones, and not covered under Medicare are not covered by Medicare under any condition. Therefore, we decided that the Plan does not have to pay for vitamin b-12 cyanocobalamin, up to 1000 mcg injection (CPT code J3420) and therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (CPT code 96372) provided on May 17, 2021, and June 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Lucentis injection you received on May 20, 2021.
You asked the Plan to waive the coinsurance for the Lucentis injection. You say that this is a medically necessary drug and it is outrageous that the Plan doesn't pay more for it. 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 Lucentis injection. The Lucentis injection falls within the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Lucentis injection you received on May 20, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy, 60 minutes with patient (CPT code 90837) on February 17, 2019, provided by yourself.
You asked the Plan to pay for the service. You say that you are requesting payment in the amount of $600. The Plan denied your request. The Plan says you are providing the behavioral health services to yourself, you are both the provider and the patient. The Plan states that neither Medicare nor the Health Plan cover a mental health provider student. The Plan states this is not a Medicare-qualified mental health care professional.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the service have not been met. Medicare does not cover student in
training, you are not a Medicare-qualified mental health care professional. Furthermore, Medicare prohibits a
physician from making referrals for certain designated health services (DHS) payable by Medicare to an entity
with which he or she (or an immediate family member) has a financial relationship (ownership, investment, or
compensation), unless an exception applies. Therefore, we decided that the Plan does not have to pay for
psychotherapy, 60 minutes with patient (CPT code 90837) on February 17, 2019, provided by yourself.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 9, 2021.
You asked the Plan to waive the copayment for the ambulance transport. You say that it was out of your control to choose how you were transported. 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 $250 copayment for each one-way ambulance transport. You have been asked to pay $240.91, which is less than the $250 copayment for the ambulance transport. The ambulance transport falls within the Ambulance 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 ambulance transport provided on January 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest you had on May 26, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you have to get a CT scan twice a year to follow-up with your post cancer treatment. Because this is a requirement, you do not think you should have to pay the copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this CT scan ($224.05) is less than your copayment obligation, you are responsible for the full allowed 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 $275 copayment for diagnostic radiology services (including CT scans). You have been asked to pay a $275 copayment for the CT scan. This copayment applies regardless of the reason for the CT scan. 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 of the chest you had on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay (CPT code 81479) and
analysis (CPT code 81291) provided to the enrollee on May 14, 2021.
You asked the Plan to pay for the services. You say that this service is not experimental. You state that it is a
pharmacogenomic test that analyzes clinically important variations that may affect the enrollee's response to
psychiatric medications. The Plan denied your request. The Plan says the service is considered experimental by
a Psychiatrist based on Medicare guidelines per LCA A56199.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. This testing is considered
experimental and investigational. Several of the performed testing, including for the MTHFR gene are not
considered to be clinically efficacious. Furthermore, per guidelines, this testing is not considered reasonable
and necessary merrily based on the member having a particular diagnosis. Pharmacodynamic testing is not
considered reasonable and necessary. Therefore, we decided that the Plan does not have to pay for the
GeneSight Psychotropic Assay (CPT code 81479) and analysis (CPT code 81291) provided to the enrollee on
May 14, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on October 29, 2020.

You asked the Plan to waive the copayment for the breast ultrasound. You say that this was your annual screening, so there should be no 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 $30 copayment for basic imaging services (including ultrasounds). 

You have been asked to pay a $30 copayment for the breast ultrasound. The breast ultrasound falls within the basic imaging services benefit category. Your Evidence of Coverage only covers screening mammograms with zero copayment. This was an ultrasound, not a mammogram, so that is why the 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 the breast ultrasound you had on October 29, 2020.
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 the pain is very bad. 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.