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

We decided that the Plan does not have to waive the copayment for a SNF stay provided from June 30, 2021, to July 17, 2021.

You asked the Plan to waive the copayment for a SNF stay. You say that 60 days had not passed since your last SNF stay. 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 $0 copayment for days 1-20, and a $160 copayment for days 21-100, per benefit, for SNF care. A benefit period starts the day you go into a hospital or skilled nursing facility. It ends when you go 60 days in a row without hospital or skilled nursing care. 

You had a SNF stay from June 30, 2021, to July 17, 2021. The record shows that you had a previous SNF stay
within the same benefit period for a total of 14 days. Therefore, you are not being charged a copayment for days 15-20 (June 30, 2021, to July 5, 2021). You are responsible to pay a $160 copayment for days 21-31 (July 6, 2021, to July 16, 2021). The total amount you owe is: $160 (copayment) x 11 (SNF days) = $1,760. 

You have been asked to pay the total copayment amount of $1,760 for a SNF stay. A SNF stay falls within the SNF 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. Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay provided from June 30, 2021, to July 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 5, 2021, to August 12, 2021.  

You asked the Plan to waive the copayment for inpatient hospital care. You say that the admission was not planned and you were not informed of the charges. 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 $395 copayment for days 1-5 for inpatient hospital care.   

You received inpatient hospital care from August 5, 2021, to August 12, 2021. Therefore, you are responsible to pay a $395 copayment for days 1-5 (August 5, 2021, to August 9, 2021). The total amount you owe is: $395 (copayment) x 5 (inpatient days) = $1,975.   

You have been asked to pay the total copayment amount of $1,975 for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital 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. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 5, 2021, to August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core buildup (D2950) provided on October 19, 2020.  

You asked the Plan to pay for dental code D2950. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D2950 is not covered under the Plan's supplemental 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, dental code D2950 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup (D2950) provided on October 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 7, 2021, to May 16, 2021.  

You asked the Plan to waive the copayment for inpatient hospital care. You say that you returned to the hospital a second time because the procedure could not be completed the first time. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. You state that you should not be responsible for the second set of charges.  

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 $325 copayment for days 1-5 for inpatient hospital care.   

You received inpatient hospital care from May 7, 2021, to May 16, 2021. Therefore, you are responsible to pay a $325 copayment for days 1-5 (May 7, 2021, to May 11, 2021). The total amount you owe is: $325 (copayment) x 5 (inpatient days) = $1,625.   

You have been asked to pay the total copayment amount of $1,625 for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital 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. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 7, 2021, to May 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound services (76705) provided on August 12, 2021.  

You asked the Plan to pay for code 76705. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  

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, we have confirmed that code 76705 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound services (76705) provided on August 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the treatment of a broken forearm bone provided on September 10, 2021.  

You asked the Plan to waive the copayment for the treatment of a broken forearm bone. You say that you did not sign up for this Plan and requested to be switched back to traditional Medicare but it took awhile. 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 $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities.  

You received the treatment of a broken forearm bone provided at an outpatient hospital facility, on September 10, 2021. The treatment of a broken forearm bone is considered an outpatient surgical procedure.  Therefore, you are responsible to pay the $300 copayment.   

You have been asked to pay a $300 copayment for the treatment of a broken forearm bone. The treatment of a broken forearm bone falls 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 the treatment of a broken forearm bone provided on September 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services provided on August 22, 2021.  

You asked the Plan to waive the copayment for ambulance services. You say that you were dropped off 3 blocks from the destination and did not receive medical services. 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 $275 copayment for ambulance services.   

You have been asked to pay a $275 copayment for ambulance services. Ambulance services fall 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 ambulance services provided on August 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ECG provided on July 29, 2021.  

You asked the Plan to waive the copayment for an ECG. You say that you do not understand why you received this bill. 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 $20 copayment for outpatient diagnostic procedures and tests.   

You have been asked to pay a $20 copayment for an ECG. An ECG falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an ECG provided on July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray of the shoulder you had on August 18, 2021.

You asked the Plan to waive the copayment for the x-ray. You say that you already paid the doctor for the same x-ray The Plan denied your request. The Plan says you did not already pay a copayment for this x-ray. The Plan says that the doctor's claim on this date includes cost sharing for a fluoroscopy service, not for a shoulder x-ray. Because this is a different service, separate cost sharing applies.

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 $35 copayment for x-rays. 

You have been asked to pay a $35 copayment for the x-ray. 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 x-ray of the shoulder you had on August 18, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on May 24, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that when you bought this insurance, you were told that this coverage was better than the plan you had. You stated that with your previous plan, you never received 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 $90 copayment for emergency room visits. 

You have been asked to pay a $90 copayment for the ER visit. 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 emergency room (ER) visit you had on May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 (K0823).
You asked the Plan to pre-approve a group two power wheelchair. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a Group 2 PWC (K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829) is covered if all the coverage criteria (a)-(e) for a PWC are met and the wheelchair is appropriate for the beneficiary's weight. 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 a group two power wheelchair. Our reviewer says that this item is not medically necessary. Our physician reviewer found the member requires a wheelchair for mobility related self-care tasks. The documentation provided does not support that he would not be able to use his arms to propel himself in a manual wheelchair. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group two power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 (K0823).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on August 24, 2021.

You asked the Plan to pay for the core buildup. You say that a core buildup is part of the process when getting a crown put on. You also say that there is no reason the core buildup should not be covered. The Plan denied your request. The Plan says this service is not a covered expense 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 core buildup, including any pins when required (D2950) provided on August 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Butrans.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. 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 Butrans.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance transportation trips provided from May 21, 2021, to June 10, 2021.

You asked the Plan to waive the copayments for ambulance trips. You say that you were told that you would have no cost-sharing for non-emergency transportation as long as there was prior authorization. The Plan denied your request. The Plan says the copayment amounts 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 $225 copayment for each one-way ambulance trip. There were 3 trips, resulting in a total copayment amount of $675. 

You have been asked to pay $225 copayment for each ambulance trip. Ambulance trips fall 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 copayments for ambulance transportation trips provided from May 21, 2021, to June 10, 2021.

Your complaint regarding receiving inaccurate information about the cost-sharing for this service is considered to be a grievance. The Qualified Independent Contractor does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the cervical spine (72050) and the x-ray exam of the shoulder (73030) rendered by the out-of-network (OON) provider on September 14, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.

We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the x-ray exam of the cervical spine (72050) and the x-ray exam of the shoulder (73030) rendered by the out-of-network (OON) provider on September 14, 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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.

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 you continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. 

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on July 6, 2021.

You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says claims are not accepted for hearing aids purchased out-of-network.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are received from a Plan provider. 

We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the hearing aids were not purchased from a Plan provider. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on July 6, 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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