Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composite (D2391) provided on July 27, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the resin-based composite. You say that you contacted the Plan to see if this provider was in-network and you were told yes. You also say that you feel that you were misinformed and would have gone to another dentist if you had been given the correct information. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.  

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 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 the resin-based composite (D2391) provided on July 27, 2021 by an out-of-network (OON) provider.   

Your complaint about possibly being misinformed by the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided on June 17, 2021.  

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says an inpatient admission is not medically necessary. Based upon records available, the care delivered is consistent with an observation stay.  

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   

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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record showed that at the time of inpatient admission it was not reasonable for the admitting physician to expect that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more toward the intraoral x-ray, surgical implant placement and drugs or medicaments provided on March 23, 2021.

You asked the Plan to pay more toward the intraoral x-ray, surgical implant placement and drugs or medicaments. You say that you don't understand why insurance paid the amount they did. The Plan denied your request. The Plan says the claim reprocessed to pay the full allowed amount for the x-ray. The implant and drugs and medicaments 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, the Plan is only obligated to pay the allowed amount for the x-ray and 30% of the allowed amount for the implant. The drugs and medicaments remain denied as a non-covered benefit. You are responsible for paying the difference between the dentist's fees and the Plan's payment to the out-of-network dentist. Therefore, we decided that the Plan does not have to pay more toward the intraoral x-ray, surgical implant placement and drugs or medicaments provided on March 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance services (A0429, A0425, A0428) provided August 12, 2021, and August 18, 2021.  

You asked the Plan to waive the copayment for the ambulance services. You say that you feel the cost of the ambulance services is too much. The Plan denied your request. The Plan says you were charged this cost sharing 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 for each ambulance trip. You had 2 ambulance trips. The Plan charged you $608.88 for these services. This means that you have been asked to pay less than or equal to the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services (A0429, A0425, A0428) provided August 12, 2021, and August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the laboratory services provided on January 28, 2021.  

You asked the Plan to waive the deductible for the laboratory services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received laboratory services combined with your Annual Preventative Wellness Gynecological Exam. Laboratory services are not covered as part of this annual wellness exam. The Plan says that the correct amount has applied towards your deductible per your contract with the Plan.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible which applies to Outpatient diagnostic tests.   

The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to Outpatient diagnostic tests.   This cost sharing is a contractual obligation that had not been met at the time the laboratory services were received on January 28, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory services provided on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a wig, any type (A9282) purchased May 1, 2021.  You asked the Plan to pay for a wig. You say that you have severe hair loss due to a medical condition called androgenetic alopecia. The Plan denied your request. The Plan says the hair/scalp prosthesis is not a covered benefit for your medical condition.  Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules.    In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. However, the health Plan offers a benefit that exceeds Medicare coverage. For this reason, the Plan's coverage rules apply in this case. The health Plan contract says that wigs are covered for members who experience hair loss due to treatment for cancer. Your diagnosis for this DME request is androgenetic alopecia. Though the Plan offers a benefit in excess of Medicare coverage, you do not meet the criteria. Therefore, we decided that the Plan does not have to pay for a wig, any type (A9282) purchased May 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 4, 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 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 August 4, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on July 23, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services provided to the enrollee on July 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) provided on August 14, 2021.  You asked the Plan to pay for the CT scan of the head or brain. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier.  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 70450 is a column II code to column I code 70496. 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 computed tomography (CT) scan of the head or brain (70450) provided on August 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on July 9, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on July 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).  You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically necessary after surgery to prevent blood clots from developing. The Plan denied your request. The Plan says this device is specifically not covered according to Medicare rules.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met.      Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darzalex, Darzalex Faspro, and Velcade.

You asked the Plan to pre-approve Darzalex, Darzalex Faspro, and Velcade. You say that these drugs are medically reasonable and necessary. The Plan denied your request. The Plan says there is no support for the requested drug regimen as first line therapy.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Darzalex, Darzalex Faspro, and Velcade. Our reviewer says that the requested drugs are not medically reasonable and necessary for the enrollee's condition. Our physician reviewer found the enrollee has been diagnosed with multiple myeloma. In this case, the requested drugs are not FDA-approved for the enrollee's condition as first line therapy also includes thalidomide, lenalidomide, or mephalan. In addition, the use of these drugs is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Darzalex, Darzalex Faspro, and Velcade have not been met. Therefore, we decided that the Plan does not have to pre-approve Darzalex, Darzalex Faspro, and Velcade.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room visit provided on July 26, 2021.  You asked the Plan to waive the copayment for the emergency room visit. You say that you sat in the emergency room for four hours before leaving. The Plan denied your request. The Plan says you have been 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 $75 copayment for each emergency room visit.     The record shows that you were triaged and examined by the emergency room staff. Therefore, you have been asked to pay a $75 copayment for the emergency room visit. Emergency room visits fall 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.   Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the observation of inpatient hospital care including admission and discharge on the same day moderate severity (50 minutes) (99235) provided on May 16, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the observation services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  

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 the observation of inpatient hospital care including admission and discharge on the same day moderate severity (50 minutes) (99235) provided on May 16, 2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on September 22, 2021.

You asked the Plan to waive the copayment for the emergency room visit. You say that the emergency room doctor advised you to return to your primary care doctor. The Plan denied your request. The Plan says you have been 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 each emergency care visit. 

You have been asked to pay a $90 copayment the emergency room visit. Emergency room visits fall 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. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided on September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on July 15, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the drug testing provided on July 15, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for hospital observation care provided on August 30, 2021.  

You asked the Plan to waive the copayment for the hospital observation care. You say that the charges are excessive for services that were not done. The Plan denied your request. The Plan says you have been 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 $395 copayment for each outpatient hospital observation visit.   

You have been asked to pay a $395 copayment for the hospital observation care. Hospital observation care falls within the Outpatient Hospital Observation 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 hospital observation care provided on August 30, 2021.   

Your complaint about being sent to observation in order to increase the bill 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder Monitor test (0012M) provided on July 7, 2021.

You asked the Plan to pay for the Cxbladder Monitor test (0012M). 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.

The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for Cxbladder testing are non-covered. 

We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the Plan does not have to pay for the Cxbladder Monitor test (0012M) provided on July 7, 2021.