Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit and a duplex scan provided by a specialist on January 13, 2020.You asked the Plan to waive the copayment for a specialist office visit and a duplex scan. You say that you do not agree with these copayments. 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/Select/specialist visit and outpatient diagnostic tests/routine radiology/Select. You have been asked to pay a $40 copayment for a specialist office visit and a $40 copayment for a duplex scan. The total amount you are being asked to pay is $80 ($40 + $40 = $80). A specialist office visit falls within the physician/practitioner services/Select/specialist visit benefit category and a duplex scan falls within the outpatient diagnostic tests/routine radiology/Select 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 and a duplex scan provided by a specialist on January 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309) provided on November 7, 2019 
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not preauthorized or emergent. There were network providers available.
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 the nursing facility care (99309) provided on November 7, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a fitting and insertion of vaginal support device provided by a participating provider on December 20, 2019.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you think you are being overcharged. 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 $250 copayment for outpatient surgery. You have been asked to pay $176.68 which is less than your copayment amount of $250 copayment for an outpatient surgery. The procedure that was provided is considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls within the outpatient surgery 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 fitting and insertion of vaginal support device provided by a participating provider on December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Novolog via Omnipod.
You asked the Plan to pre-approve Novolog via Omnipod. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Disposable Durable Medical Equipment is not a covered benefit of Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Novolog via Omnipod have not been met. Specifically, Omnipod is a disposable system. Therefore, we decided that the Plan does not have to pre-approve Novolog via Omnipod.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 27, 2019 by a non-network 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 a non-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 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 the medical services provided on November 27, 2019 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient office visit provided on October 22, 2019 by an out of network (OON) provider. You asked the Plan to pay for an outpatient office visit. You say that you would like this claim reprocessed and approved for payment. 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 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 an outpatient office visit provided on October 22, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings is a medically necessary part of the enrollee's treatment plan and you request an appeal. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve an epidural injection for the enrollee.You asked the Plan to pre-approve the requested injection. You say that the enrollee is in pain, and the service will be done in the office setting.The Plan denied your request. The Plan says that there are no contraindications for imaging guidance with contrast media.The Plan follows Medicare rules. Medicare rules say that epidural injections are covered only under certain medical indications. The file shows that a lumbar injection without imaging guidance (CPT Code 62322) was requested. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested injection. Our physician reviewer found that the enrollee has a diagnosis of lumbar spinal stenosis without neurogenic claudication. The enrollee has failed conservative treatments including Tramadol, Lidocaine patch, Prednisone, Gabapentin, and Lorazepam. In light of the enrollee's severe pain during the Covid-19 pandemic, this procedure will be done in the office setting, as the hospital is not doing non-emergency services. It is documented that the injection would be done above the site of the enrollee's previous hemilaminectomies using static imaging (PA and lateral films) prior to the injection for verification. At this time it is medically reasonable and necessary to perform this requested injection without image guidance with contrast media, as it is not available.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested injection have been met. Therefore, we decided that the Plan has to pre-approve an epidural injection for the enrollee.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for your inpatient hospital stay from December 4, 2019 to December 9, 2019 at your Tier 1 benefit.
You asked the Plan to pay for your inpatient hospital stay from December 4, 2019 to December 9, 2019 at your Tier 1 benefit. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received inpatient hospital services at a Tier 2 facility. The Plan states the correct copayment has applied per your contract with the Plan.
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 $275 copayment per day for days 1-6 and a $0 copayment for days 7-90 for Inpatient hospital care. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received inpatient hospital care at a Tier 2 Plan facility. You have been asked to pay a $275 copayment per day for days 1-5 for your inpatient hospital stay from December 4, 2019 to December 9, 2019 at your Tier 1 benefit, totaling $1375. Your inpatient hospital stay falls within the Inpatient hospital 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 pay for your inpatient hospital stay from December 4, 2019 to December 9, 2019 at your Tier 1 benefit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary,rest home visit provided on November 20, 2019.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 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 a domiciliary, rest home visit provided on November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit and coinsurance for an injection provided by an in-network provider on January 14, 2019.
You asked the Plan to waive the copayment for an office visit and coinsurance for an injection. You say that you've never been charged this much for your knee injections before. The Plan denied your request. The Plan says the correct copayment and coinsurance 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 $35 copayment for physician/practitioner services/in-network/provider and a 20% coinsurance for Medicare Part B prescription drugs/in-network. You have been asked to pay a $35 copayment for an office visit and a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $1,138.56. The total amount owed for the injection is $227.71 ($1,138.56 x 20% = $227.71) The total amount you are being asked to pay is $262.71 ($35 + $227.71 = $262.71). An office visit falls within the physician/practitioner services/in-network/provider and professional services/specialist benefit category. An injection falls within the Medicare Part B prescription drugs/in-network 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 and coinsurance for an office visit and injection provided by an in-network provider on January 14, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
You asked the Plan to pre-approve the CT scan. You say that in order to properly assess whether the enrollee is benefitting from treatment, he needs restating studies. The Plan denied your request. The Plan says Medicare pays directly for care associated with a clinical trial, not the Medicare Advantage plan.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve the CT scan as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) 
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not preauthorized or emergent. There were network providers available.
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 the psychotherapy services (90832)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 1, 2019 and December 6, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 physician's 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 physician's services provided on November 1, 2019 and December 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray and periodontal exam you received on December 3, 2019.
You asked the Plan to pay for the dental services. You say that this should be covered The Plan denied your request. The Plan says these are not covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. The Plan covers only preventive oral exams and bitewing x-rays. Periodontal exams and intraoral x-rays are not covered. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray and periodontal exam you received on December 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arterial catheterization (36620) provided on September 19, 2019.You asked the Plan to pay forthe arterial catheterization. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this service was billed with an inappropriate diagnosis code.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the arterial catheterization. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that the member was hemodynamically unstable, undergoing cardiothoracic surgery, receiving a transfusion or in need of beat-to-beat blood pressure monitoring.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the arterial catheterization have not been met.Therefore, we decided that the Plan does not have to pay for arterial catheterization (36620) provided on September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the dental services (D0120) provided on November 19, 2019.You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that the services are not covered.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. Specifically, the Plan is denying payment for the dental services (D0120) stating you were not enrolled on the date of service at issue in this appeal. However, the Plan has not provided any documentation showing that you were not enrolled with the plan or documentation showing that you were enrolled with a different Plan. According to the Medicare Beneficiary database, the enrollee has been contracted with the plan since May 1, 2016. The Medicare database does not show that the enrollee has enrolled in any other Plan since May 1, 2016. Without this information we cannot verify that the Plan's denial is accurate.Therefore, we decided that the Plan has to pay for the dental services (D0120) provided on November 19, 2019.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 pay foran office visit provided on December 5, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says thatthere is no network deficiency for these services and alternate network providers were found.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 fromout-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 foran office visit provided on December 5, 2019 by an out of network (OON) provider