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

We decided that the Plan does not have to waive the copayment for SNF care provided to the enrollee from November 4, 2020, through December 2, 2020.
You asked the Plan to waive the copayment for SNF care. You say that the enrollee was supposed to be discharged on November 3, 2020. You state that during the enrollee's stay they contracted COVID-19 and was forced to stay until December 2, 2020. The Plan denied your request. The Plan says the claim was processed accordingly with the enrollee's 2020 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 he first day of this skilled nursing benefit period began with the enrollee's admission to this provider on November 4, 2020, as the enrollee did not have any prior skilled nursing facility admissions within the previous 60 days. Because of this, the enrollee is only responsible for eight (8) days of SNF cost-share ($160 copayment per day x 8 days = $1,280). 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 copayment for SNF care provided to the enrollee from November 4, 2020, through December 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 3, 2020.
You asked the Plan to pay for the laboratory services. 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on August 3, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that you were told that you would not owe a copayment until 2021. 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 $10 copayment for laboratory services. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall 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 laboratory services provided on August 3, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy session, 60 minutes (90837} provided on October 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that the service was provided with no adequate time frame to obtain authorization for the service. The enclosed medical records clearly reflect the medical necessity of the services rendered. 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 individual psychotherapy session, 60 minutes (90837} provided on October 29, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 17, 2020 to August 21, 2020.
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 procedure codes G0452 and 81403 are not supported.
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, the CPT Code Manual definition of code G0452 is molecular pathology procedure; physician interpretation and report. The definition of code 81403 is Level 4 molecular pathology procedure. We find that CPT codes G0452 and 81403 are not supported in the medical record. Specifically, there is no documentation for the billed dates 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 laboratory services rendered on August 17, 2020 to August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services provided on November 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for wound care services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan say that there are in-network providers available for these services.
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 wound care services provided on November 13, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
You asked the Plan to provide a therapeutic continuous glucose monitor. You say that you cannot get enough blood for finger stick testing. The Plan denied your request. The Plan says you are not on insulin therapy therefore criteria is not met for a CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation provided does not indicate that you use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an oxygen concentrator (E1390).

You asked the Plan to pre-approve an oxygen concentrator. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested equipment is not reasonable and necessary.

The Plan follows Medicare rules. Medicare rules say that recertification for oxygen equipment is granted when certain criteria are met as detailed 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 an oxygen concentrator. Our reviewer says that a home oxygen concentrator is medically necessary for the enrollee. Our physician reviewer found that the enrollee has chronic obstructive pulmonary disease (COPD) and has been on oxygen at night. The medical records include overnight oximetry on January 28, 2021, on room air, showing hypoxemia for 382 minutes. There are no indications of obstructive sleep apnea in the medical record. The patient is not obese.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator have been met. Therefore, we decided that the Plan has to pre-approve an oxygen concentrator (E1390).

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: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay up to the $1,000 maximum annual benefit for the panoramic x-ray and
consultation. We decided that the Plan does not have to pay more than the $1,000 maximum annual benefit for
the panoramic x-ray and consultation.
You asked the Plan to pay for the panoramic x-ray and consultation. You say that you believe these services
should be covered. The Plan says that these services were rendered by a Medicare opt out provider. The Plan
also says that you signed a financial agreement acknowledging that the provider did not accept Medicare.
We decided that the Plan has to pay up to the $1,000 maximum annual benefit for the panoramic x-ray
and consultation.
The rules say that the health plan must provide you with a clear and accurate description of the Original
Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including
applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits.
The rules also say that Medicare plans must make reasonable and diligent efforts to gather and forward
information to the IRE.
The record shows that you received care from a Medicare opt out provider. The contract does not clearly state
that services rendered by a Medicare opt out provider would not be covered. The Plan says that the enrollee
signed a financial agreement with the provider acknowledging that the provider did not accept Medicare. You
also have an annual maximum benefit of $1,000 for preventive and comprehensive services. The Plan did not
provide a copy of the signed financial agreement between the provider and yourself. You reasonably believed
that these services would be covered up to the $1,000 maximum benefit. Therefore, we decided that the Plan
has to pay up to the $1,000 maximum annual benefit for the panoramic x-ray and consultation.
We also decided that the Plan does not have to pay more than the $1,000 maximum annual benefit for
the panoramic x-ray and consultation.
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 does not need to pay more
than $1,000 for preventive and comprehensive dental services. Therefore, we decided that the Plan does not
have to pay more than the $1,000 maximum annual benefit for the panoramic x-ray and consultation.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visual field exam provided on December 21, 2020.
You asked the Plan to waive the copayment for the visual field exam. You say that you believe this service should be billed under your annual exam. The Plan denied your request. The Plan says the copayment has processed correctly, and no reimbursement is due.
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 Medicare-covered vision care. You have been asked to pay a $20 copayment for the visual field exam. The visual field exam falls within the Medicare-covered vision 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 the visual field exam provided on December 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the routine electrocardiogram (ECG) with
at least 12 leads, including the tracing, interpretation, and report (93000) provided August 6, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that you should not owe a cost
share because you believe you have already reached your 2020 out of pocket maximum. The Plan denied your
request. The Plan says the claim was processed, and the copayment was applied correctly per the Evidence of
Coverage.
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
copayment for Medicare covered non-radiological diagnostic services.
You have been asked to pay $14.48 for the diagnostic service. Since the allowed amount is less than the
copayment amount, you are responsible for the lesser amount. The diagnostic service 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 the routine electrocardiogram (ECG) with at least 12 leads, including the tracing,
interpretation, and report (93000) provided August 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
December 11, 2020, through December 12, 2020.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says an acute inpatient stay is not supported based on the information received.
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 based on the medical records provided there is no expectation notated of ab inpatient hospital stay for more than 2 midnights. There are no concerning factors or alarming symptoms or signs that would lead to anticipation of an inpatient stay greater than 2 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 from December 11, 2020, through December 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for individual therapy provided by a participating provider on January 11, 2021.
You asked the Plan to waive the copayment for individual therapy. You say that you were told that three visits would be covered. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for physician/practitioner services/individual therapy. You have been asked to pay a $20 copayment for individual therapy. Follow-up visits are still subject to copayments; therefore, the correct copayment has been applied. Individual therapy falls within the physician/practitioner services/individual therapy 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 individual therapy provided by a participating provider on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99309) provided on November 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON nursing facility care. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.
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 nursing facility care (99309) provided on November 11, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for a CT scan provided on June 29, 2020.

You asked the Plan to waive the co-payment for a CT scan. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly, and the enrollee is 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 co-payments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 co-payment for diagnostic radiology services

The enrollee has been asked to pay the allowed amount of $213.58, which is less than the $300 co-payment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and 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 co-payment for a CT scan provided on June 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee is receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a
participating provider on January 27, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that you were told to go to the
wrong doctor. You say that because of this you do not feel like you should have to pay for this visit. The Plan
denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for physician/practitioner services/specialist.
You have been asked to pay a $40 copayment for a specialist office visit. Since a specialist office visit was
provided, the correct copayment has been applied. A specialist office visit falls within the
physician/practitioner services/specialist benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment
for a specialist office visit provided by a participating provider on January 27, 2021.