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

We decided that the Plan does not have to waive the coinsurance for the CPAP device and humidifier provided on December 25, 2019.
You asked the Plan to waive the coinsurance for the CPAP device and humidifier. You say that you don't understand how you are being charged separately for each part when the parts come together. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare-covered DME items and certain drugs that are used with nebulizers, insulin pumps, and IV infusion pumps. You have been asked to pay a total of $12.75 for the CPAP device and humidifier.
Equipment
Allowed Amount
Coinsurance
Member Liability
CPAP Device
$43.38
20%
$9.68
Humidifier
$15.34
20%
$3.07
TOTAL:
$12.75
The CPAP device and humidifier fall within the "Durable Medical Equipment (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 the CPAP device and humidifier provided on December 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants (CPT D6010).You asked the Plan to pre-approve the dental implants. You say that you need dental implants to hold your dentures in place.The Plan denied your request. The Plan says dental implants are not covered under the enrollee's benefit package.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 items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve dental implants (CPT D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0862) and accessories.You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the requested group 3 power wheelchair and accessories are medically necessary.The Plan denied your request. The Plan says the requested group 3 power wheelchair does not meet criteria.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 pre-approve a group 3 power wheelchair and accessories. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a medical history of orthostatic hypotension, morbid obesity fibromyalgia, chronic fatigue, allergic rhinitis, migraine headache, functional dyspepsia, obstructive sleep apnea, and hypertension. The records indicate the enrollee is a functional quadriplegic and is wheelchair-confined. A power mobility device with multiple power options is now recommended. This is not medically necessary as a lesser device such as a group 2 power mobility device would appear to be capable of addressing this enrollee's mobility needs. This is a convenience request and is not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 3 power wheelchair and accessories have not been met.Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0862) and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prescription of optical and physical characteristics of and fitting of contact lens (92310) provided December 11, 2019.
You asked the Plan to pay for the contact lens fitting. You say that this visit is a result of your medical conditions that require you to have annual visits. The Plan denied your request. The Plan says the payment for this service is included in the cost of the primary physician visit.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the contact lens fitting has a bundled relationship with code 92014 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for prescription of optical and physical characteristics of and fitting of contact lens (92310) provided December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on May 20, 2019 to May 30, 2019 by an out of network (OON) provider.You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 subsequent nursing facility care services provided on May 20, 2019 to May 30, 2019 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 provided on January 14, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 laboratory testing 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 January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on November 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency 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 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 medical services provided to the enrollee by an out-of-network provider
on November 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on
December 29, 2019 through January 2, 2019.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you would like
reconsideration because this copayment is not included in the member's EOC and the member is on social
security and unable to pay this bill. The Plan denied your request. The Plan says there is a $372 copayment
each day for days 1-5 and the member was admitted to an inpatient stay for 4 days.
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 enrollees
must pay a $372 copayment each day for days 1-5 for Inpatient Hospital Care.
The enrollee has been asked to pay a $1,488.00 copayment for 4 days of inpatient hospital services. The
inpatient hospital services fall within the Inpatient Hospital Care 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 copayment for inpatient hospital services provided on December 29, 2019 through January 2,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 24, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because the provider is not a specialist. 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. The record shows that you received services from a physician that is considered a specialist on January 24, 2020. Therefore, you are responsible to pay the $40 copayment. 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 January 24, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99284) and abscess drain (10060) provided on June 19, 2018. You asked the Plan to pay for the emergency department visit and abscess drain. You say that you would like reconsideration because your claim was initially filed timely. The Plan denied your request. The Plan says the claim was received on December 26, 2019 which is past the allowed 12-month timeframe. The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the emergency department visit and abscess drain was not filed until December 26, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99284) and abscess drain (10060) provided on June 19, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from December 28, 2019 to December 29, 2019.
You asked the Plan to pay for the medical services. You say that the enrollee was seen by multiple physicians under different specialties on the same date of service. The Plan denied your request. The Plan says the billed evaluation and management service was bundled as part of the global surgical fee.
The Plan must follow Medicare rules. Medicare rules say that components of a global surgical package include follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery.
The file shows that the enrollee received medical services that were related to the surgical procedure provided on December 24, 2019. The services were provided during the surgical procedure's global surgery period. This means that the services are included in the global surgery fee. The services are not separately payable. Therefore, we decided that the Plan does not have to pay for the medical services provided from December 28, 2019 to December 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 28, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on December 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on November 18, 2019.You asked the Plan to waive the copayment for the endoscopy. You say that you weren't informed you would have to pay.The Plan denied your request. The Plan says the copayment 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 $25 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.You have been asked to pay a $25 copayment for the endoscopy. The endoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 endoscopy provided on November 18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic laryngoscopy provided on October 31, 2019 to December 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a diagnostic laryngoscopy. You say that the member is a return patient. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no referring 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 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 a diagnostic laryngoscopy provided on October 31, 2019 to December 4, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan rendered on April 23, 2019.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. 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 $125 copayment for Medicare-covered diagnostic radiology (MRI, CT, PET).
Review of the file shows that you received a CT scan on April 23, 2019. You have been asked to pay a $125 copayment for these services. These services fall within the Medicare-covered diagnostic radiology (MRI, CT, PET) 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 computed tomography (CT) scan rendered on April 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on December 5, 2019.You asked the Plan to pay for the drug test. 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 drug test.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 drug test provided on December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia injection services.
You asked the Plan to pre-approve the Prolia injection services. You say that the records provided support the
need for the requested drug. The Plan denied your request. The Plan says Prolia is not medically necessary. The
Plan says that it is not known if the enrollee's bone mineral density T-score is -2.5 or lower at the total hip,
femoral neck, or lumbar spine. The Plan says that it is not known if the enrollee has a history of a fragility
fracture.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 the Prolia injection services. Our
reviewer says that Prolia injection services are not medically reasonable and necessary. Our physician reviewer
found Prolia has been requested for the treatment of post-menopausal osteoporosis. The information provided
by your provider does not meet Medicare's guideline.
The review has determined that the documentation does not support that the Prolia is medically reasonable and
necessary. The documentation does not support that the Prolia is safe and effective for the enrollee. The
enrollee does not meet the criteria laid out in the LCD for coverage of the requested drug. Specifically, the
diagnosis of osteoporosis is not met.
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 Prolia injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fordermatology services provided on March 1, 2019 through October 17, 2019.You asked the Plan to pay forthe dermatology services. You say that you would like reconsideration because you were told that dermatology services are covered.The Plan denied your request. The Plan says a referral is needed for the services in question but one was not obtained.The Plan must follow Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the dermatology services have not been met. Specifically, the Health Plan contract clearly states that a referral is needed for services provided by a specialist.Therefore, we decided that the Plan does not have to pay fordermatology servicesprovided on March 1, 2019 through October 17, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from December 9, 2019 to December 13, 2019.You asked the Plan to pay forhome health services. You say that you would like reconsideration because you are not required to submit a treatment authorization code.The Plan denied your request. The Plan says home health claims are required to have the treatment authorization code and q code to process and pay the claim. The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was submitted without the required treatment authorization code and q code.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from December 9, 2019 to December 13, 2019.