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 from May 1, 2021, to  May 23, 2021.  

You asked the Plan to waive the copayment for a SNF stay. You say that you received inadequate care during your SNF stay. The Plan denied your request. The Plan says the proper copayment was 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 $0 copayment each day for days 1 to 20 and a $125 copayment each day for days 21 to 28 for Skilled Nursing Facility (SNF) Care. The day of admittance into the SNF was May 1, 2021, and the discharge date was  May 23, 2021. With days 21 and 22 being billed a copayment amount of $250 ($125 copayment x 2 days).     

You have been asked to pay $0 copayment each day for days 1 to 20 and a $125 copayment each day for days 21 to 22 for Skilled Nursing Facility (SNF) stay for a total of $250. A SNF stay falls within the Skilled Nursing Facility (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 from May 1, 2021, to May 23, 2021.   

Your complaint about your experience with this provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the gauze (CPT code A6266-KX) provided to the enrollee on September 2, 2021.  You asked the Plan to pay for the gauze. You say that the cost of this equipment should not have been denied as it was needed for the enrollee's healing. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).  Review of the file shows that the enrollee received office services provided on September 2, 2021. The enrollee was asked to pay a $45 copayment for the services. The enrollee's 2021 EOC states enrollees must pay a $45 copayment for each specialist's office visit. Furthermore, A6266-KX is denied because the DME service was billed with an incorrect place of service. Review of the claim summary shows the DME service, A6266, billed with place of service 11 (Office). According to the Medicare Claims Processing Manual, Chapter 20, section 10 and section 100.2.1.d, the DME must be for use in the patient's residence other than a healthcare institution and payment cannot be made for equipment for use in an institution. In addition, the charges for these services should also reflect the place for which the DME will primarily be used i.e. the patient's residence. However, the Explanation of Benefits does not show that the Plan is charging the enrollee for the gauze (CPT code A6266). Therefore, the enrollee is asked to pay the $45 copayment for the office services.  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 pay for the gauze (CPT code A6266-KX) provided to the enrollee on September 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on July 21, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transport benefit. If no transport of a Medicare beneficiary occurs, then there is no Medicare covered services.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on July 21, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on July 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient rehabilitation provided May 21, 2021 to June 10, 2021.  You asked the Plan to waive the copayment for the inpatient rehabilitation. You say that this was a single admission and only one copayment should be applied. The Plan denied your request. The Plan says you were transferred from an inpatient hospital to a rehabilitation facility. A new copayment applies with each admission to a different type of facility.  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 per day copayment for days 1 to 5 of each inpatient admission.  You have been asked to pay a $1250 per day copayment for the first 5 days of an inpatient rehabilitation admission. This was a new admission from the inpatient hospital admission. 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 rehabilitation provided May 21, 2021 to June 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided on July 8, 2021.  You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 physical therapy services provided on July 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator provided on  June 2, 2021.  You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that you feel that the Plan should reimburse 80% of the full cost of the concentrator. The Plan denied your request. The Plan says the correct coinsurance was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for each durable medical equipment (DME) item, including oxygen equipment.   For DME, the enrollee's Evidence of Coverage says that they are responsible for 20% of the allowed amount, and the Plan is responsible for 80% of the allowed amount. The allowed amount for the oxygen concentrator is $108.87. The enrollee is responsible for $21.77, which is 20% of the allowed amount ($108.87 allowed amount x 20% coinsurance = $21.77). The Plan's share for the oxygen concentrator is $87.10, which is 80% of the allowed amount ($108.87 allowed amount x 80% Plan responsibility = $87.10). The file shows that the Plan reimbursed the enrollee $87.10, which is 80% of the allowed amount as the Plan's responsibility for the oxygen concentrator.  The oxygen concentrator falls within the Durable Medical Equipment (DME) and Related Supplies 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 coinsurance for an oxygen concentrator provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the evaluation and management services provided on August 25, 2021.  You asked the Plan to pay for the services provided. You say that you received a well woman visit at your primary care physician's office. The Plan denied your request. The Plan says that the service was billed as a non-payment claim.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.  We looked at the file and the rules. The file shows that the services at issue were provided by a contract provider. The file does not show that the Plan provided notice that the services provided would not be covered. Under Medicare rules, this means the services provided is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the evaluation and management services provided on August 25, 2021.   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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the thorax, diagnostic; without contrast material (71250) provided on September 15, 2021.  

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $750 yearly deductible. This is the amount you have to pay out-of-pocket before the Plan will pay their share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Once you have paid your deductible, the Plan will begin to pay their share of the costs for covered medical services and you will pay your share (your copayment or coinsurance amount) for the rest of the calendar year. A $200 copayment is applied after the deductible is met for each advanced imaging service.    

You have been asked to pay $414.40 for the CT scan provided as you had not met the yearly deductible. This is the Plan's allowed amount 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 copayment for the computed tomography (CT) scan of the thorax, diagnostic; without contrast material (71250) provided on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye refraction provided on July 21, 2021.  You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the eye refraction was provided by a non-par vision provider.  Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by the Plan's vision provider.  We looked at the file and the Plan's rules. The file shows that the eye exam was not provide by the Plan's vision care provider. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on July 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170).  You asked the Plan to pre-approve additional mileage. You say that you have a plate, and you are receiving treatment and will need a total of 5 trips to complete the process. You have no other means of transportation and you do not want to delay your treatment. You also say that the transportation company is willing to take you, but they need an authorization from the Plan. The Plan denied your request. The Plan says you are requesting an additional 16.5 miles for a total of 91.5 miles and your benefit only allows 75 miles. The Plan also says you have exceeded your benefit limit.    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 up to 60 one-way trips and each one-way trip must not exceed 75 miles of driving distance.   We looked at your request, the records in the case file, and the rules. Specifically, trips over 75 miles are not covered. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lab services (G0482) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve lab services (G0482) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar injections provided on August 9, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the services provided. You say that the claim is supported with documentation. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.

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 lumbar injections provided on August 9, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided September 9, 2021.  You asked the Plan to pay for the comprehensive oral exam. You say that you have 2 cleanings covered by the Plan. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.  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. The Plan covers the comprehensive oral exam once every three plan years.   We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam was previously covered on January 19, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded.  Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided September 9, 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 does not meet criteria.

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 enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to easy fatigue and dizziness with therapy. 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on July 2, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for these services. You say that you disagree with the denial. 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 requested provider in this case is not a network provider with the Plan. The referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 2, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for bitewing, single x-rays (D0270) provided June 22, 2021.  You asked the Plan to pay for the dental services. You say that you disagree with the denial of the x-ray which was needed to detect a problem before it needed to be pulled. The Plan denied your request. The Plan says this service exceeds the Plan's benefit frequency limitation of one procedure per Plan year.  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. The health Plan contract says that the Plan covers one procedure per Plan year. The records show this service was provided and covered for date of service March 16, 2021.  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 bitewing, single x-rays (D0270) provided June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray rendered on May 13, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.  The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.  We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on May 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health services you received from August 21, 2021, to August 31, 2021.

You asked the Plan to waive the copayment for the inpatient mental health services. You say that you believe the total copayment should only be $90. 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 $325 copayment per day for days 1-5, and a $0 copayment for days 6+ for inpatient mental health care.

Records show that you were an inpatient for ten days. You were charged a $325 copayment per day for each of the first five days of this stay, for a total of $1625. This copayment applies even if you are admitted to the hospital through the emergency room. 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 mental health services you received from August 21, 2021, to August 31, 2021.