Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient physician services provided to the enrollee on July 8, 2020.
You asked the Plan to pay for this service. 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 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 has network providers available who can provide 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 outpatient physician services provided to the enrollee on July 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient surgical services rendered on June 22, 2020.You asked the Plan to waive the copayment forthese services. You say that you thought the services were going to be covered in full.The Plan denied your request. The Plan says the copayment was applied 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 $295 copayment for each Medicare-covered surgical services in an ambulatory surgical center. Review of the file shows thatyou received outpatient surgical services in the form of an upper endoscopy on June 22, 2020. You have been asked to pay a $295 copayment for these services. These services fall within the Medicare-covered surgical services in an ambulatory surgical center 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. The file shows that the Plan reviewed your call history and found you contacted the Plan on May 21, 2020 and were advised that the procedure by a physician is covered at 100 percent and there is a $295 copayment for services at an ambulatory surgical center.Therefore, we decided that the Plan does not have to waive the copayment forthe outpatient surgical services rendered on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe $35 copayment charged for specialist services provided on July 22, 2020.You asked the Plan to waivethis copayment. You say that you do not believe this copayment is correct.The Plan denied your request. The Plan says this copayment is a contractual obligation based on the claim submitted by the provider and your Plan contract agreement.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 $35 copayment for specialist services. 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 waivethe $35 copayment charged for specialist services provided on July 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete maxillary denture (D5110) and a complete mandibular denture (D5120).You asked the Plan to pre-approvethe complete maxillary denture and complete mandibular denture. You say that you choke when you try to eat.ThePlan denied your request. The Plan says these services exceed the maximum count allowed per period.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan'scoverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on March 5, 2018, and your complete maxillary denture (D5110) and complete mandibular denture (D5120) benefits have been exhausted.Therefore, we decided that the Plan does not have to pre-approvea complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99213) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you would rather go to another doctor outside of this provider office because your eye surgery was a horrible experience as the doctor damaged and deformed your eye during surgery. 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the outpatient office visit (99213) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea pneumatic compression device (E0652).You asked the Plan to providea pneumatic compression device. You say that the enrollee has swelling beyond the extremities and has failed conservative therapies.The Plan denied your request. The Plan says there is no documentation that the enrollee has lymphedema of the trunk, abdomen or chest.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,multiple-hour home usage of the E0650 or E0651 is required.
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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.The record does not show lymphedema of the trunk, abdomen or chest. Therefore, we decided that the Plan does not have to providea pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network cardiac monitoringand physician services provided to the enrollee from  February 18, 2020, to February 27, 2020.You asked the Plan to pay forthis service. 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 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 has network providers available who can provide 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 forout of network cardiac monitoring and physician services provided to theenrollee from  February 18, 2020, to February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that this doctor came recommended. The Plan denied your request. The Plan says there are tertiary level care providers in-network 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waivethe $90 copayment charged for emergency room services provided on June 10, 2020.You asked the Plan to waivethis copayment. You say that you do not believe this bill is correct.The Plan denied your request. The Plan says you are only responsible for the $90 copayment which is your contractual obligation.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles andcoinsurance). Your contract with the Plan clearly says that you must pay $90 copayment for emergency room services. 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 waivethe $90 copayment charged for emergency room services provided on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe primary care physician (PCP) services rendered on April 1, 2020.You asked the Plan to waive the copayment forthese services. You say that you would like the copayment removed.The Plan denied your request. The Plan says the copayment was applied 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 $10 copayment per visit for PCPs for Medicare-covered services. Review of the file shows that you received PCP services on April 1, 2020. You have been asked to pay a $10 copayment for these services. These services fall within the PCP visit for Medicare-covered services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This costsharing 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 forthe primary care physician (PCP) services rendered on April 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve specialist services. You say that you would like approval to see this provider. The Plan denied your request. The Plan says 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approvecontinuation of SNF care from December 1, 2020, forward.You asked the Plan to pre-approveSNF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Benefit periods doinclude inpatient hospital stays but the Plan didn't give us evidence of hospital stays. Furthermore, the gap between November 2019, and June 2020, is longer than sixty (60) days. It appears that there are seventeen (17) additional days in the benefit period beginning on June 25, 2020, as of December 1, 2020, and the Plan has to cover SNF care until these 17 days are used or proper notice is given.Therefore, we decided that the Plan has to pre-approvecontinuation of SNF care from December 1, 2020, forward.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/orsend 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approveF2 and F5 genetic testing for the enrollee.You asked the Plan to pre-approvethe testing. You say thatthis is medically necessary.The Plan denied your request. The Plan says this is not covered except for pregnant patients.The Plan must follow Medicare rules. Medicare rules say that F2 and F5 testing are only covered for pregnant patients. The enrollee does not qualify for this testing. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pre-approveF2 and F5 genetic testing for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto make additional payment forhearing aids received on July 13, 2020.You asked the Planto make additional payment forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe plan has paid the maximum amount.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids with a benefit of up to $1000 per year. Additional payment cannot be made for the hearing aids, as the plan has already paid $1000 to date for them. Based on this information, we decided that the Plan's rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto make additional payment forhearing aids received on July 13, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on June 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says 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 has network providers available who can provide 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 specialist services provided on June 23, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean emergency alart/response system.You asked the Planto pre-approvethe system. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plandoes not haveto pre-approvean emergency alart/response system.
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 November 26, 2019.
You asked the Plan to pay for this service. 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 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 has network providers available who can provide 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 November 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea tub stool or bench(E0245).You asked the Plan to pre-approvethis item. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a tub stool or bench may be appropriate for you in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea tub stool or bench (E0245)
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services provided to the enrollee from May 27, 2020, to July 15, 2020 and billed under code S9328.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says this code is statutorily excluded for Medicare claims.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, this code cannot be paid as billed. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forhome health services provided to the enrollee from May 27, 2020, to July 15, 2020 and billed under code S9328.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services providedon July 24, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain authorization from the plan prior to seeking care. In this situation, you will pay the same as you would pay if you got the care from a network provider.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 laboratory services. 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 laboratory services provided on July 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or forpatients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea total electric hospital bed.You asked the Plan to pre-approvethe requested hospital bed. The Plan denied your request. The Plan says a total electric hospital bed is not covered by Medicare for any reason.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvea total electric hospital bed.