Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on November 12, 2020.
You asked the Plan to pay for the orthosis. You say that the orthosis was medically necessary. The Plan denied your request. The Plan says that documentation indicates services are not necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on November 12, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMS HF System.
You asked the Plan to pre-approve implantable wireless pulmonary artery pressure sensor with delivery
catheter, including all system components (C2624) and transcatheter implantation of wireless pulmonary artery
pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor,
right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and
pulmonary artery angiography, when performed (33289).
You say that the system is medically necessary. The Plan denied your request. The Plan says that in order for
the CardioMEMS device to be covered the enrollee would need to be in a Medicare approved study.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
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 implantable wireless pulmonary artery
pressure sensor with delivery catheter, including all system components (C2624) and transcatheter implantation
of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment
and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological
supervision and interpretation, and pulmonary artery angiography, when performed (33289).
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this
case. Our physician reviewer found given the severe symptoms of recurrent congestive heart failure which
appears very sensitive to volume loading conditions, the complexity of the medical regimen and the failure to
prevent acute congestive heart failure hospitalization in this patient, use of the CardioMEMS device is
reasonable and has both clinical data and expert opinion to back up its use in selected appropriate clinical
situations like this one.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of implantable wireless pulmonary artery pressure sensor with delivery catheter,
including all system components (C2624) and transcatheter implantation of wireless pulmonary artery pressure
sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart
catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary
artery angiography, when performed (33289) have been met. Therefore, we decided that the Plan has to preapprove
a CardioMEMS HF System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on February 25, 2021.
You asked the Plan to waive the coinsurance for DME. You say that you were told when you signed up with the Plan that you would not be charged anything for DME. 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 20% coinsurance for DME and related supplies. You received DME on February 25, 2021. The total allowed amount is $668.31 and 20% of that is $133.66. You have been asked to pay the total coinsurance amount of $133.66 for DME. DME falls within the DME and related 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 coinsurance for DME provided on February 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) care provided from November 5, through December 1, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that she must pay a $0 copayment per day, for days 1-20 and a $160 copayment per day, for days 21-100 for skilled nursing facility care.

The enrollee has been asked to pay $960 ($160 copayment x 6 days) for the inpatient skilled nursing facility care provided. This means that she has been asked to pay the correct amount based on her 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 the inpatient skilled nursing facility (SNF) care provided from November 5, through December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for two tooth extractions (D7140) provided on October 9, 2020, by an out-of-network provider.

You asked the Plan to waive the coinsurance for the extractions. You say that you were told you were covered for up to $1,000 a year. You feel the Plan should pay the full bill because you had not met your annual maximum yet. The Plan denied your request. The Plan says while the Plan does cover a maximum of $1,000 for supplemental dental services each year, you are also responsible for 50% of the billed charges for services received out-of-network. After you meet the $1,000 annual maximum, you are responsible for 100% of charges.

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 50% coinsurance for preventative and comprehensive dental services received out-of-network.

You have been asked to pay 50% coinsurance for the tooth extractions. Tooth extractions fall within the preventative and comprehensive dental services benefit category, and in this case were received from an out-of-network provider. 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 two tooth extractions (D7140) provided on October 9, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chronic care management services (99490) rendered by the out of network (OON) provider on December 16, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.

We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the chronic care management services (99490) rendered by the out of network (OON) provider on December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dental cleaning (D1110) provided on September 25, 2020, by an out-of-network provider.
You asked the Plan to waive the coinsurance for the dental cleaning. You say that you were told you were covered for up to $1,000 a year. You feel the Plan should pay the full bill because you had not met your annual maximum yet. The Plan denied your request. The Plan says while the Plan does cover a maximum of $1,000 for supplemental dental services each year, you are also responsible for 50% of the billed charges for services received out-of-network. After you meet the $1,000 annual maximum, you are responsible for 100% of charges.
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 50% coinsurance for preventative and comprehensive dental services received out-of-network.
You have been asked to pay 50% coinsurance for the cleaning. A dental cleaning falls within the preventative and comprehensive dental services benefit category, and in this case were received from an out-of-network provider. 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 the dental cleaning (D1110) provided on September 25, 2020, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 12, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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 rendered on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for two tooth extractions (D7140) provided on March 2, 2020, by an out-of-network provider.
You asked the Plan to waive the coinsurance for the extractions. You say that you were told you were covered for up to $1,000 a year. You feel the Plan should pay the full bill because you had not met your annual maximum yet. The Plan denied your request. The Plan says while the Plan does cover a maximum of $1,000 for supplemental dental services each year, you are also responsible for 50% of the billed charges for out-of-network services up to this allowance.
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 50% coinsurance for preventative and comprehensive dental services received out-of-network.
You have been asked to pay 50% coinsurance for the tooth extractions. Tooth extractions fall within the preventative and comprehensive dental services benefit category and were received from an out-of-network provider in this case. 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 two tooth extractions (D7140) provided on March 2, 2020, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered from November 19, 2020 to November 20, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider.
Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered from November 19, 2020 to November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5298) purchased on February 15, 2021.
You asked the Plan to pay for the hearing aids. You say that the Plan's provider charges more than double the price for hearing aids, so you used another provider. You feel you should be reimbursed the allowance amount because you feel this benefit is unethical and hearing aids should be covered from any provider, since the allowance amount would remain the same. The Plan denied your request. The Plan says hearing aids are only covered when they are purchased from the specified Plan provider.
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 only when they are purchased from the Plan's specified hearing provider. We looked at the file and the Plan's rules. These hearing aids were purchased out-of-network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5298) purchased on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walker purchased for the enrollee on February 9, 2021.

You asked the Plan to pay for the walker. You say that you did not know this needed to be order from a specific provider. The Plan denied your request. The Plan says that this is excluded from coverage under Medicare.

The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who is not enrolled in the Medicare Program. 

The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the walker purchased for the enrollee on February 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical and occupational therapy (97165, 97530, 97110) provided on January 29, 2021, to February 4, 2021, by an out of network (OON) provider.

You asked the Plan to pay for physical and occupational therapy. You say that the services were medically necessary. The Plan denied your request. The Plan says services were provided 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 physical and occupational therapy (97165, 97530, 97110) provided on January 29, 2021, to February 4, 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 a specialist visit provided on February 24, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you would not have gone to the visit if you had known that the provider could not allergy test you. 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 $40 copayment for specialist visits.
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 visit provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on January 22, 2021.
You asked the Plan to waive the copayment for an office visit. You say that you were sick and the physician's office said they don't see sick people. 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 primary care provider visits. You have been asked to pay a $10 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 office visit provided on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cryosurgery procedure.
You asked the Plan to waive the copayment for the cryosurgery procedure. You say that you believe you had this procedure in a doctor's office, so there should be no copayment. The Plan denied your request. The Plan says this copayment was charged correctly. The facility where you had this procedure is considered an outpatient hospital facility.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for surgery in an outpatient hospital facility. You have been asked to pay a $150 copayment for the cryosurgery procedure. The cryosurgery procedure falls within the surgery in an outpatient hospital facility 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 cryosurgery procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walker and transport chair provided from July 15, 2020 to October 28, 2020.
You asked the Plan to pay for these items. You say that these items were medically necessary. The Plan denied your request. The Plan says that the provider is not under contract with the health plan and is not certified with Medicare.
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who is not enrolled in the Medicare Program. The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the walker and transport chair provided from July 15, 2020 to October 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on December 16, 2020 by an out of network (OON) provider.

You asked the Plan to pay for home health 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.

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 home health services provided on December 16, 2020 by an out of network (OON) provider.