Persius/hicric huggingface dataset:
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 based on the documentation provided the enrollee only requires short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current 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: 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 the enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is 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 problem focused limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on September 27, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation and panoramic x-ray. You say that you went to the dentist for your annual checkup which is free. You also say that you were charged for an problem focused oral evaluation and were not told you would be charged for this exam or x-rays. The Plan denied your request. The Plan says these services are not covered benefits under your plan. The Plan also says that the dental office contacted the Plan on September 27, 2021 and were advised that they were in-network and only preventive dental services are a covered benefit under your 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. Your plan only covers preventive services including routine cleanings and bitewing x-rays. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital services (99233) provided on September 12, 2020.  

You asked the Plan to pay for the hospital care. You say that the enrollee did not provide insurance information for some time, and the claim was submitted as quickly as this information was provided. The Plan denied your request. The Plan says this claim was submitted more than one year from the date of service and is therefore untimely. The Plan contacted a provider representative who confirmed that no other payers were billed prior to the receipt of this claim.  

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  

The record shows that a claim for the hospital care was not filed until September 29, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the hospital services (99233) provided on September 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a comprehensive hearing test (92557) provided on September 9, 2021.  You asked the Plan to waive the copayment for a hearing test. You say that you do not need to pay for this copayment because you are entitled to one free examination under your plan benefits per year. The Plan denied your request. The Plan says the copayment you are being charged is correct.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for each Medicare-covered diagnostic hearing exam.        You have been asked to pay a $5 copayment for a hearing test. The EOC confirms you receive one routine hearing test every year. The records show that you did not have a routine hearing test. Specifically, the medical records show that you had a diagnostic hearing test. The EOC confirms that $45 is the required copayment for this service. You have been asked to pay a copayment of $5, which is less than the Plan's contracted amount. 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 comprehensive hearing test (92557) provided on September 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a biopsy or excision of lymph node (38500) provided on August 27, 2021, at an outpatient hospital facility.  You asked the Plan to waive the copayment for a biopsy or excision of lymph node. You say that on the day of your procedure you were quoted and paid a lower copayment. The Plan denied your request. The Plan says the correct 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 a $345 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.    You have been asked to pay a $345 copayment for a biopsy or excision of lymph node. A biopsy or excision of lymph node falls within the Medicare-covered surgery or other services provided to you at an outpatient hospital 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 biopsy or excision of lymph node (38500) provided on August 27, 2021, at an outpatient hospital facility.   Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibility from a representative of the 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and pulpal debridement (D3221) provided on September 21, 2021.  You asked the Plan to pay for the dental services. You say that you were experiencing terrible tooth pain. You say that it was determined you needed a root canal. You say that it should not be expected for you to have to pay for this when you were in a painful, emergency situation.  You also say that you assumed you were referred to an in-network endodontist. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan says that the frequency limit has been exceeded. The Plan also says that pulpal debridement is not listed as a covered 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.  Though the Plan offers a dental benefit in excess of Medicare coverage and limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on September 16, 2021. Additionally, pulpal debridement is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), and pulpal debridement (D3221) provided on September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for cataract surgery (66984) provided on August 13 and August 27, 2021, at a Tier 2 ambulatory surgical center.  

You asked the Plan to waive the copayments for cataract surgery. You say that you were informed that your cost was going to be $300 and you paid in full. The Plan denied your request. The Plan says the correct copayments were 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 $400 copayment for Medicare-covered surgery or other services provided to you at a Tier 2 ambulatory surgical center.   

You have been asked to pay $800, or a $400 copayment per instance for two instances of cataract surgery. Cataract surgery falls within the "Outpatient Surgery and Other Medical 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 copayments for cataract surgery (66984) provided on August 13 and August 27, 2021, at a Tier 2 ambulatory surgical center.   

Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibilities from a representative of the 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for urgent care services provided on September 18, 2021.  You asked the Plan to waive the copayment for the urgent care services. You say that the urgent care facility did not provide you with the services you needed. 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 a $65 copayment for each urgent care visit.     You have been asked to pay a $65 copayment for urgent care services. Urgent care services falls within the Urgently needed 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 urgent care services provided on September 18, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Fluid Flow skin substitute application for the enrollee.  You asked the Plan to pre-approve the procedure. You say that this is medically necessary for Achilles tendinitis and pain of the right foot. The Plan denied your request. The Plan says the doctor must send a medically reasonable explanation for why this application is needed to qualify for coverage.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is not necessary to treat the enrollee Achilles tendinitis and pain on the right side. During a medical visit dated 12/3/21, the pain on the right side was noted to be 80% better. The physician has discontinued immobilization, and has ordered the the enrollee an ankle brace for continued treatment. There is no justification for the injection of the fluid flow skin substitute to the right Achilles tendon, especially since the enrollee is doing much better as of December 2021. There is no documentation of increased pain during a medical visit after that date.  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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Fluid Flow skin substitute application for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient hospital facility fee (48199) and general anesthesia (00170).

You asked the Plan to pre-approve the outpatient services. You say that the enrollee requires multiple extractions in order to maintain function and to get rid of oral infection. You say that the enrollee has a history of failed moderate conscious sedation and severe dental phobia. You say that a general anesthetic will be necessary due to the enrollee's history and the length of the procedure required. The Plan denied your request.

The Plan says the requested services are not covered in an outpatient setting regardless of whether the dental service is covered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

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 outpatient services. Our reviewer says that the requested dental services to be provided in an outpatient setting are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation does not indicate there is a need for in patient hospitalization for the extractions to be performed. The reviewer found that there would be no inpatient hospitalization required. Under the provisions of Medicare there would be no coverage for any aspect of the dental treatment, including anesthesia which is directly related to the dental procedures. Therefore, the reviewer found that the dental services to be provided in an outpatient setting are not medically necessary. 

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 outpatient services have not been met. Specifically, the file does not indicate there is a need for in patient hospitalization for the extractions to be performed. Therefore, we decided that the Plan does not have to pre-approve outpatient hospital facility fee (48199) and general anesthesia (00170).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a medical eye exam (92014), deluxe frames (V2025) and bifocal sphere lenses (V2200) provided on September 25, 2021.  You asked the Plan to pay for a medical eye exam, deluxe frames and bifocal lenses. You say that it is hard to find convenient medical care in your area. You also say you would like the Plan to review and reconsider payment. The Plan denied your request. The Plan says services will only be covered when they are received from a provider in the specified vision network.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when services are rendered by a contracted provider.  We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. The Plan covers eyewear when they are received from a provider who participates in the Plan's specified vision network. Based on this information, we decided that the Plan's rules for coverage of a medical eye exam, deluxe frames and bifocal lenses have not been met. Therefore, we decided that the Plan does not have to pay for a medical eye exam (92014), deluxe frames (V2025) and bifocal sphere lenses (V2200) provided on September 25, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency room services rendered on September 23, 2021.  

You asked the Plan to waive the copayment for emergency room services. You say that the Plan's nurse called an ambulance and the police on you without your consent after you shared your feelings about suicide and the police took you to the hospital. You also say you do not believe you should have to pay this bill. 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 $90 copayment for in-network emergency room care.   

You have been asked to pay a $90 copayment for emergency room services. 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 emergency room services rendered on September 23, 2021.   

Your complaint about the potential actions of the Plan's nurse 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for cataract surgery (66984) provided on September 23, 2021, by an out-of-network provider.  You asked the Plan to pay for cataract surgery. You say that the services at issue were a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.  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 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 cataract surgery (66984) provided on September 23, 2021, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a laparoscopy (49655) rendered on April 8, 2021.  You asked the Plan to waive the coinsurance for a laparoscopy. You say that there is no effort being made by the Plan to clarify coverage variations dependent upon whether a surgical procedure is performed in a hospital versus a surgical center location and that the difference here is a reasonable copayment versus a greater amount of cost participation resulting in approximately $1,800 variation. 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 20% coinsurance for each covered surgery or observation room service in an outpatient hospital.   You have been asked to pay $1,702.22 in coinsurance, which is 20% of the allowed amount for a laparoscopy ($8,511.09 allowed amount x 20% coinsurance = $1,702.22). A laparoscopy 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 coinsurance for a laparoscopy (49655) rendered on April 8, 2021.   Your complaint about the potentially poor customer service 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.