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

 We decided that the Plan does not have to pay for the infusion supplies with pump provided from April 21, 2021 through April 27, 2021.    You asked the Plan to pay for the infusion supplies with pump. You say that you are not a hospice provider and services were started past the date of hospice. You say that the claim should be reprocessed for payment as hospice dates did not overlap. The Plan denied your request. The Plan says Original Medicare is responsible for payment.  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Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.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 April 15, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the infusion supplies with pump provided from April 21, 2021 through April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core buildup and endodontic therapy provided on May 13, 2021 and June 2, 2021.  You asked the Plan to pay for the core buildup and endodontic therapy. You say that you were told you could spend up to $3,000 per year on your teeth and you did not agree to be charged for anything outside of what insurance covers. You say that no out-of-pocket expense was agreed on and you were not informed you weren't covered. The Plan denied your request. The Plan says the claim processed correctly.  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, you also have a maximum benefit of one root canal every year. The Plan paid for the root canal provided on May 13, 2021, which exhausted your benefit. The core buildup remains denied as a non-covered benefit. Therefore, we decided that the Plan does not have to pay for the core buildup and endodontic therapy provided on May 13, 2021 and June 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for after cataract laser surgery (66821) and an outpatient hospital clinic visit (G0463) rendered on June 22, 2021.

You asked the Plan to waive the copayment for after cataract laser surgery and an outpatient hospital clinic visit. You say that at no time were you advised of a facility charge, nor does the Plan provide or allow for such a charge. You also say you have disputed the charge. The Plan denied your request. The Plan says you were 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 $275 copayment for Medicare-covered outpatient services at hospital facilities.

You have been asked to pay a $275 copayment for after cataract laser surgery and an outpatient hospital clinic visit. After cataract laser surgeries and outpatient hospital clinic visits fall within the Outpatient Surgery, including services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for after cataract laser surgery (66821) and an outpatient hospital clinic visit (G0463) rendered on June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional routine transportation.  You asked the Plan to pre-approve the additional routine transportation. You say that you would like reconsideration because you require transportation for your surgery and follow-ups. The Plan denied your request. The Plan says you have exhausted your routine transportation benefit.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 one-way trips per year.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower denture (D5120) provided on March 8, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a complete upper denture and a complete lower denture. You say that you would like to be reimbursed for the dental services done at an OON dental office. The Plan denied your request. The Plan says there is no coverage for when services are rendered by an OON provider.  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 and you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower denture (D5120) provided on March 8, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the wearable automatic external defibrillator (the LifeVest) you rented on March 30, 2021, and April 30, 2021.  You asked the Plan to waive the coinsurance for the LifeVest. You say that you are suffering from cancer and do not need the added stress of these bills. 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 durable medical equipment.   You have been asked to pay 20% coinsurance for the LifeVest. The LifeVest falls within the durable medical equipment 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 wearable automatic external defibrillator (the LifeVest) you rented on March 30, 2021, and April 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the removal of a non-cancerous skin growth of the neck (11422) and repair of subsequent wound of the neck (12041) rendered by an ambulatory surgical center on August 2, 2021.

You asked the Plan to waive the copayment for the removal and repair of a neck cyst. You say that you were told you received stitches, but the incision was glued instead. You say you are appealing your cost-share. The Plan denied your request. The Plan says you remain liable for the copayment. The Plan's decision was made in compliance with your benefits and Medicare rules.

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, including services provided at hospital outpatient facilities and ambulatory surgical centers. 

You have been asked to pay a $336.49 copayment for the removal and repair of a neck cyst, which falls within the Outpatient Surgery benefit category. According to your contract with the Plan, surgical procedures provided at an ambulatory surgical center requires a $350 copayment. The facility at which you received services is an ambulatory surgical center. This can be confirmed in the Plan's 2021 Physician/Provider Directory, as stated in your contract. 

Since the Plan's allowed amount ($336.49) is less than the required $350 copayment, you are responsible for the charges. 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 removal of a non-cancerous skin growth of the neck (11422) and repair of subsequent wound of the neck (12041) rendered by an ambulatory surgical center on August 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ground transportation services (A0427, A0425) rendered on June 12, 2021.  You asked the Plan to waive the copayment for ground transportation services. You say that you feel the copay should be covered, waived, or changed. You also state that you have not been billed in the past for ambulance service that you received on several occasions, so you do not understand why you are being billed now. The Plan denied your request. The Plan says you were charged the correct copayment 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 $225 copayment for per day for Medicare-covered, ambulance round-trip services.    You have been asked to pay a $225 copayment for ground transportation services. Ground transportation services 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 ground transportation services (A0427, A0425) rendered on June 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the knee brace you received on May 20, 2021.  You asked the Plan to waive the coinsurance for the knee brace. You say that you feel as though you were fitted for an incorrect brace.  You said that you tried to return the brace but the provider would not take it back. You do not think you should have to pay this coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that they confirmed with the provider, and you were advised that this item was not returnable.  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 prosthetic devices, including braces.   You have been asked to pay 20% coinsurance for the knee brace. The knee brace falls within the prosthetic devices benefit category. This coinsurance applies regardless of your satisfaction with this item. 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 knee brace you received on May 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane 60 mg/3 ml (J7318) in the right knee.

You asked the Plan to pre-approve Durolane. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, Orthovisc and Monovisc.

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 Durolane. Our reviewer says that Durolane is not medically necessary. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the Plan's preferred drugs, Monovisc and Orthovisc. The reviewer found that the record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred drugs. Therefore, the reviewer found that the elements of the step therapy criteria 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 Durolane have not been met. Specifically, the file shows that the enrollee has not tried and failed the Plan's preferred drugs. Therefore, we decided that the Plan does not have to pre-approve Durolane 60 mg/3 ml (J7318) in the right knee.
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 January 26, 2021, to January 28, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you have not received a bill and you believe these charges are incorrect. 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 $295 copayment per day for days 1-6 for inpatient hospital care.   Records show that you were in the hospital for two days.  You were charged a copayment of $295 per day, for a total of $590. 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 January 26, 2021, to January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the visit you had with an out-of-network oncologist on June 21, 2021.  You asked the Plan to reduce the copayment for the out-of-network oncology visit. You say that when you called the office, you were told that the provider was in-network.  You believe you should only have to pay the in-network cost sharing. 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 $60 copayment for visits with an out-of-network specialist.   You have been asked to pay a $60 copayment for the out-of-network oncology visit. The out-of-network oncology visit falls within the visits with an out-of-network specialist benefit category. The Plan cannot be held responsible for incorrect information you may have been given by this out-of-network provider's office. 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 copayment for the visit you had with an out-of-network oncologist on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cone beam computed tomography (CT) image capture (D0383) and two restorative procedures (D2999 x2) provided on April 12, 2021, and June 3, 2021.  You asked the Plan to pay for the cone beam CT image capture and restorative procedures. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.  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 cone beam computed tomography (CT) image capture (D0383) and two restorative procedures (D2999 x2) provided on April 12, 2021, and June 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the pre-admission screening and clinical documentation supports an inpatient rehabilitation level of care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the services needed in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but does not require an intensive inpatient rehabilitation therapy program. There is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on July 19, 2021.  You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendering dentist has opted-out of Medicare.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Evidence was provided to show that the rendering dentist has opted-out of Medicare from August 12, 2015, to August 12, 2023. Therefore, we decided that the Plan does not have to pay for dental services provided by an out-of-network provider on July 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency care or pay for the self-administered drugs provided on May 26, 2021.  You asked the Plan to waive the copayment for the emergency care and to pay for the self-administered drugs. You say that you were in the emergency room and received the self-administered drugs. You also say that you were not advised these services would not be covered. The Plan denied your request. The Plan says the copayment amount that you are being charged for the emergency care is correct. The Plan also says that self-administered drugs are not Part B covered.  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 rules also say that Medicare Part B generally does not pay for self-administered drugs. Your contract with the Plan clearly says that you must pay an $80 copayment for each emergency room visit for Emergency Care.   You have been asked to pay an $80 copayment for each emergency room visit for the emergency care. The emergency care falls within the Emergency Care 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. Also, 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 waive the copayment for the emergency care or pay for the self-administered drugs provided on May 26, 2021.   Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for self-care management and specialist services provided by a participating provider on July 12, 2021.  You asked the Plan to waive the copayment for self-care management and specialist services. You say that you do not agree with both copayments. The Plan denied your request. The Plan says the correct copayments have been applied.  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 outpatient rehabilitation services and a $20 copayment for physician/practitioner services/specialist.   You have been asked to pay a $20 copayment for self-care management and a $20 copayment for specialist services. The total amount you are being asked to pay is $40 ($20 + $20 = $40). Self-care management falls within the outpatient rehabilitation services benefit category and specialist services falls within the physician/practitioner services/specialist 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 self-care management and specialist services provided by a participating provider on July 12, 2021.